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} <br /> ` APPLICATION FOR PERMIT �]� ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELiON AVE.,.STOCKTON, CA <br /> Telephone 12091 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 /> q 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 / City Lot Size P PM <br /> j <br /> Owner's.Name _ � .Address � <br /> �, i Phone <br /> .. 5WF- �i <br /> Contractor Address—J-9License N Phone <br /> TYPE OF WELL/PUMP: VNEWWELL ❑ WELL REPLACEMENT-0 DESTRUCTION ❑ a <br /> ` PUMP INSTALLATION ❑ w� SYSTEM�REP IR El,, OTHER 171DISTANCE TO NEAREST: SEPTIC TANK, SEWER.LINE8\� ' DISPOSAL F,LD:- , - PROE. 'LINE <br /> .,;..FOUNDATION"' AGRICULTURE.. OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF-WELL PR>nta <br /> C STRUCTION SPECIFICATIONS <br /> ❑ Industrial } �.❑ Open Bottom ❑ ia'of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private, ❑ Gravel Pack ❑ ^•Type of Casing -..-Specifications <br /> I I'1 Public l i Other ❑ th of,Grout Seal Type of Grout <br /> I Irrigation Approx. Depth I1 ..Surface Seal Installed byRepair,Work Done ❑ Type of Pump _ , .- State Work Done <br /> i Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 i f� <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION i.l DESTRUCTION-/ ii-(No-septic-system-permitted if public sewer is <br /> t 'available within 200 feet.) <br /> Installation will serves"--Residence_ Commercials` Other = <br /> Number of#[ living tuber units: + Nu `of bedroom <br /> f Character of soil to a depth oV3 feet: Water table depth <br /> SEPTIC TANK �-C ` e/Mf TV .� r { <br /> � 9 � Capacity j No. Compartments <br /> PKG. TREATMENT PLT. ❑ 4 � Method of Dispos <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 /s FoundationProperty Line <br /> i SEEPAGE PITS [ I Depth r r <br /> P Size Number <br /> II SUMPS L7 Distance to nearest'- `Well .96 0 — Foundation Property Line <br /> i 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 /> t 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 /> I certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ,p'ersons'subjectto workman's'cornpensa- <br /> tion laws of California." <br /> The:pplAicamust call for I require inspections. Complete drawing on reverse side.Signd Title: 414_4 L�?/� Date:. ! � <br /> i } <br /> t FOR PARTMENT USE ONLY <br /> tA 3 <br /> Application Accepted by Date r Aipa,. <br /> i <br /> Pit or Grout inspection by bate Final Inspection by Date is <br /> I r. <br /> l Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> INFO' +Y AMO�0_ <br /> UNT D�U)Ef)� AMOIJNT,REMITTED GASH —RECEIVED-By'— DATE" PERIVIFT NO <br /> + E 13.26[REV.I/n 51 EHH 11-28 -- I <br />