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APPLICATION FOR,PERMIT <br /> SAN JOAQUIN LOCALHEALTHDISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 �( <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; <br /> (Complete in Triplicate) <br /> District for permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin local Health <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 /> 4,7 c? /lf C City a L Lot Size PM <br /> Job Address .- <br /> yu�l;l FJ� a� hone 3 / <br /> Owner's Name Address e1 <br /> Contractor's Name �'� r <br /> 4" Q License Na. `3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONA. Mkt5Type <br /> ICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WEA CONS UCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Botto ' Dia of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private E3 Gravel PackP <br /> e of Casing Specifications <br /> ❑ Public d OtherD th of Grout Seal Type of Grout <br /> ❑ Irrigation _�4pprox. Su a Seal Installed byRepair Work Done ❑ Type of Pump .P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septi system <br /> permfeeitted if public sewer is <br /> avaInstallation will serve: Residence_ Commercial Other <br /> Number of living units: Q Number of bedrooms—0 <br /> /_da <br /> Character of soil to a depth of 3 fee: al2�y a�'d`'� A" Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> I <br />` Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation 24g .- Property Line /0 <br /> SEEPAGE PITS 13Depth Size Number <br /> 1 <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line ,y <br /> DISPOSAL PONDS ❑ a <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 per <br /> is issued, 1 shall not <br /> i employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature t <br /> Y <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> r tion laws of Califomia.:' <br /> l The applicant must call for all required inspections. Complete drawing on reverse side. <br /> a�,�f'o`- Date: <br /> Signed `�f Title: <br /> FO lD PARTMENT,USE ONLY <br /> Date / Area <br /> i Application Accepte y' Z <br /> Pit or Grout Inspect <br /> i y ate Final Inspection by <br /> Additional Comments: f <br /> 7104 ❑ Tracy 835-6386 <br /> ❑ Stk 466-6i781 El Lodi 369-3621 ❑ Manteca 823 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 16011. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE. AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> { +EH 13.24 IREV.10!831 <br /> EH 14-26 <br />