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0 {,rjt, it &4- APPLICATION FOR PERMIT <br /> O Z Vv1- t_'''" (7 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'V 7 `'�' 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> �f PtRMIT 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 i <br /> Local Health District.' <br /> O� K �a0 <br /> Job Address a City Lot Siz(/ PM <br /> Owner's Name Address LI� "� �/P ��''� — Phone <br /> 466 2 <br /> Contractor s� Address <br /> fir, r0 No. Phone �! <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ a OTHER ❑ ' <br /> DISTANCE TO T: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM STRUCTI CATIONS <br /> ❑ Industrial ' ❑ Open Bottom ❑ Manteca o Well x Dia. of Well Casing <br /> II ❑ Domestic/Private' ❑ Gravel Pack ❑ T Type of Casing Specifications' <br /> I M Public g H Other' Cl Delta Depth of Grout Seal Grout <br /> 11 irrigation ` rox. Depth I 1 Eastern Surface Seal Installed by - <br /> Repair Work Done 'Type of Pump H.P. <br /> State Work Done <br /> Well Destruct' C3 Well Diameter Sealing Material (top 50'1 <br /> w <br /> Depth Filler Material (Below 50'i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION o septic system permitted if public sewer is available within 200.feet.i <br /> • <br /> Installation will serve: Residence_ Commercial Other 7 <br /> iNumber of living units: Number of bedrooms ` <br /> i Character soil to a depth of 3 feet: Water table depth <br /> -SEPTIC TANK Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well o Pr _ <br /> LEACHING LINE D No. & Length of lines Total length/size ~ <br /> FILTER BED ❑ Distance t est: Weil Foundation Property Line <br /> F SEEPAGE PITS I Depth Size Number <br /> SUMP L� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject-to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject.to workman's compensa- <br /> tion laws of California." <br /> The applica must call fo all r inspectio s. Complete drawing on r arse side. <br /> I <br /> Signed X Title: Dater <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Al Date Area O ! <br /> Pit or Grout Inspection by Date Final li spection b Da k" <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Me teca 823-7104 ❑ <br /> Applicant - Return all copies to: Environmental Health ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 1 /?-(J <br /> rl� InJ <br /> ' FEE AMOUNT DUE AMOUNT REMITTED ASR RECEIVED BY DATE PER O. <br /> INFO <br /> ...�.EH 1324 IREV.I In sl <br /> i EH 14-2e <br />