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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA w <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. " <br /> Job Address `� / J r <br /> r�� City U at Size a PM �+~ <br /> Owner's Name, �117b "1 " A`dres <br /> Pho`ne'✓-�' <br /> Contractor Address License No. Phone \ <br /> TYPE OF WELL/PUMP: ..f,�'NEW WELL ❑ WELL R,EP,L-ACEMENT ❑ DESTRUCTION Ll [� <br /> PUMP`INSTALLATION ❑ _,�SYSTEM REPAIR D OTHERp� t� <br /> DISTANCE TO NEAREST: $EPTIC TANK --SEWER LINES DISPOSAL FLD. PROP. LINE 0 <br /> ,FOUNDATION .._ Z'_ AGRICULTURE WELL OTHER WELL PITS/SUMPS,_ ! <br /> INTENDED USE TYPE OF WELD PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 o\ <br /> EIIndustrial ❑ Open Bottom ❑IManfeca`�s Dia. of Well Excavation Dia. of WeiCasing <br /> 1 <br /> EDDomestic/Private LJGravel Pack" F-1TracyS I Type of Casing Specifications k <br /> ❑ Public FI Other/ ❑ Delta Depth of Grout Seal Type of Grout _ <br /> ! I Irrigation Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work bone <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> fi { <br /> Depth Filler Material is ow 5011 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION ESTRUCTION f I kNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _2her ! <br /> Number of living units:;Number of bedrooms ( 4 <br /> Chara ter of soil to a depth of 3 feet: fl_kL Water table depth <br /> SEPTICTANK - t <br /> }❑ Type/Mfg Capacity �e� No, Compartments <br /> PKG, T EATMENT PLT.[❑ r <br /> _ _ethod of Disposal ! <br /> Distance to nearest;— Well-� t Foundation Property Line <br /> LEACHING LINE No. & Len th of lines '" <br /> t g �� ti ) T t length/size I <br /> FILTER;BED D pistance to ne rest: Well 'Foundatiok 1 Property ILine <br /> SEEPAGE PITS 'I 1} Depth ;; A�r Size Number <br /> i <br /> SUMPS; rr- <br /> Distance to nearest: Well�fi Foundation Property Line <br /> DISPOSAL PONDS ❑ 3 \ <br /> I hereby certify that I have prepared this application and that thb"work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sari.Joaquin Local Health District- '�f � } <br /> Home owner or licensed agent'saignature certrries the following: <br /> '-'I certify that in the performance of the work for which this permit is issued, I shall not 27. <br /> employ any person in sucti manner as to become subject to wo*man�s3,compensation laws bf California."Contractor's hiring or sub-contracting signature <br /> certifies the folio 'ng: "I certify that in the performance of the work foriwhich';his permit is issLed,V`half employ parsons subject to workman's compensa- <br /> tion laws of Cal "o ia." <br /> The apglican call fdll r ui d inspec" &,A[; naplete-drawing-on-rave a side. <br /> I J <br /> Signed 7( 7itle:`"" ' EJ; i'� <br /> Date: `-�4T <br /> " FOR DEPAR MENT USE ONLY \ j, �1 .1 <br /> APplicaiion Accepted by / /� <br /> Date � t Area rG � r <br /> Pit or GLt Inspection by�: Date r• -- ` + Final Inspection by pate <br /> M <br /> Additional Comments: f f <br /> ❑ Stk 466-6781 ❑l.Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> , <br /> INFO FEF °'MOUNT DUE AM)UNT;REMITlEI]�' ' RECEIVED BY i <br /> �Q�r 'V CASH DATE PERMIT'NO. <br /> r EH 13-2.,(REV,1/n51 r•f' .�-y� <br />