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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 /> 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 O City Lot Size PM <br /> Owner's Name Address Phone ci <br /> ! + v <br /> r (/ 7 <br /> Contractor 417'4 <br /> ddress License N0. Phone/ -5 G <br /> TYPE OF WELL/PUMP: F NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> k PUMP INSTALLATION ❑ SYSTEMREP IR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW LINES DISPOSAL FLD. PROP. LINE — <br /> k FOUNDATION AGRI LTURE LL OTHER WELL PITS/SUMPS,, <br /> k •INTENDED USE TYPE OF WEZtern <br /> ONSTRUCTION SPECIFICATIONS❑ In strial- ❑ Open BottomDia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/,Priivate 't ❑ Gravel PackType of Casing Specifications <br /> ("1 Public f ' ' , F1 OtherDepth of Grout Seal Type of GroutI 1 Irrigation , : Approx.`DSurface Seal Installed by <br /> Repair Work Done,`'sE7 Type of Pump State Work DoneWell Destruction Well Diameter eainANial <br /> terial (top 50') <br /> IDepth Filler IBelo 50') <br /> TYPE OFSEPTICWORK: NEW INSTALLATION I] REPAIR/ADDITION DESTRUCTION I I (No septic system permitted it public sewer is O <br /> I' :i '•.i i available within 200 feet-) <br /> Installation will serve: .Residence Commercial_ Other <br /> s <br /> 1 Number of living units: Number of bedrooms y' �.+r <br /> `:Character of soil to a depth of 3 test: ' w" '"'� '" Water-table depth <br /> k SEPTIC TANK ❑ Type/Mfg Capacity I ZU c;2 No. Compartments <br /> -PKG. TREATMENT PLT. E❑ `� ,: f Method of Duos <br /> Distance-to nearest: Well .s� Foundation Property Line <br /> - <br /> CEACHING LINE ❑ No:&i Length.of lines Tota length/size tr} <br /> t •s h .• . J/�(� <br /> FILTER BED', EI Distance to nearest- Well LZ Foundation roperty Line <br /> ' SEEPAGE PITS- FI I Depth Y- Size n — N mbar <br /> SUMPS a L-1Distanceto n a f st:, Well L7 oundation Property Line 4 Z4 477 <br /> DISPOSAL PONDS ❑- <br /> j I hereby certify that I have prepared this application and that the work will be done in accordance with San'Joa(quin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health DiMrict. <br /> ,i 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 /> l employ any person in such mariner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> I. 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 /> r•: The applican I call fo� equ0 inspections. Complete drawing on reverse side. Y t <br /> Signed X Title: ._/ Date: <br /> FP=—ENT USE ONLY <br /> Application Accepted by r ; Date Area <br /> l { '.z_ ,� _.__ 7 �s <br /> Pit or Grout Inspection by f Data Final Inspection by Date <br /> I Additional Comments: A&L,0121 L / - y7 <br /> [IStk' 466-6781 _;D-Lodi-369:3621 ❑ Manteca ,823-7104 O Tracy 835-&395 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> kINF *;AMOUNT DtlE�`� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-24 1REV.I/H 5k JWL�lq <br /> l '?0-64EH 14-28 + <br />