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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 /> 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 /> I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 for well pump and the Rules and Regulations of the San Joaquinh <br /> Local Health District. A ` <br /> City Lot Size � + PM <br /> Job Address �,/ <br /> Owner's Name Address V / �J -- <br /> Contractor dress <br /> 3ff <br /> TYPE OF WELL/PUMP:` NEW W LL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> License No. Phone <br /> INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST. SEP IC NK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIO AGRICULTURE OTHER WELL PITS/SUMPS V <br /> I INTENDED USE TYPE OF WELL OBLEM A CONSTRUCTION SPECIFICATIONS <br /> i � I <br /> ' ❑ Industrial ❑ Open Bottom ❑ ca Dia. of.Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private,.. .,f❑Gravel Pack Tracy Type of Caking Specifications <br /> C1 Public El"her ❑ Delta "" ` y `of Grout Seal Type of Grout <br /> I lied b <br /> ❑ Irrigation \4M 'p Depth ❑ Eastern Surface Se y <br /> Repair Work Done ` 'sof Pump WP. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> A Depth L Filler Material IBelow 50'1 11 <br /> TYPE OF SEPTIC WORKe�NEW'INSTALLATION ❑ aEPAIR/ DITION ❑ DESTRUCTI N ❑ INo septic system permitted if public sewer is <br /> :.° X01! ■available within 200 feet.) <br /> l Instillation will server Residence— Commercial T Of er k <br /> ' Number of living units: Number of bedrooms s Jt.lJl <br /> r Character of soil to a depth of 3 feet: 88 Water table depth # <br /> SEPTIC TANK ❑ .,Type/ <br /> 6 Cap ity No. Compartments <br /> l PKG. TREATMENT P.L7. ❑' <br /> ~"J Meth# Disposal <br /> . pi-tante to nearest: Well Foundation party Lin <br /> 4 <br /> a LEACHING LINE ❑ No,-& Length of lines % """ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> -ti - <br /> t tNumber t E" <br /> SEEPAGE PITS ❑ Depth � ���- Si��� f .�. <br /> SUMPS ❑ . .Distant nearest: Well - + Foundation Property Line <br /> ! DISPOSAL PONDS ❑ ° <br /> hereby certify that I have prepared this application and that the work will be done in accordance with S 'oaquin county ordinances, state(laws, and <br /> rules and regulations of the San Joaquin,,Local,,Health DistiicL IL 1 —" <br /> Homeowner or licensed agent's signature'certifies the following: "I certify that in the performance of the work for ich this permit is issued,b shall not <br /> employ any person in such manner as to become subject to workman$s compensation laws of California."Contractors hiring or sub-contracting'signature <br /> certifies the following:"I certify that in the performance of the work for wtiicli this permit is issued,I shall employ persons subject to workman's dompensa- <br /> tion laws of California." <br /> The applic t must call for all re ired inspections. Complete drawing on reverse side. <br /> -3 -2- �7 <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY r <br /> l F,e _ —Z Area �' <br /> Application Accepted by Date — <br /> c Pit or Grout Inspieation b y Date Final Inspec ion 6 r Date -�" <br /> .... /gyp k <br /> s rn. i <br /> Additional Cor6n)A ' I <br /> ❑ V466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823-71041. O Tracy <br /> Applicant- Return all copies,to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> F FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMiT`N0. <br /> INFO CASH <br /> +EH 13.24[REV.Fla 5}.,..,.-,....-. .- -�...�.r, .. ,....g �/�/S / Ob <br /> EH 14-28 _ <br />