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APPLICATION FOR PERMITS <br /> SAN JOAQUIN,.LOCAL HEALTH DISTRICT <br /> 2- 5 <br /> 1601 E. HAZETON AVE.,:STOCKTON, CA , <br /> Telephone (209) 466-6781 <br /> ih PERMIT EXPIRES 1 YEAR' 'FROM DATE ISSUED <br /> (Complete in Triplicate) rr - r*3 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein riescri <br /> 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 he Sanlrcation Joaquin <br /> Local Health District. <br /> Job Address +� '_ S' ] Tia R_- <br /> ar c ., City Lot Size PM <br /> � r <br /> Owner's Name I Address ��_. 7 + <br /> Phone <br /> Contractor Address I[ <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C CATIONS <br /> ❑ Industrial ❑ Open Bottom eco Dia. of Wefl Excavation <br /> ❑ Domestic/Private Dia. of Well Casing <br /> e Pack ❑ Tracy Type of Casing <br /> ❑ Public ❑ OtherSpecifications <br /> ❑ DeltaT� bepth of Grout Seat Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern urface Seal lnstalled by <br /> Repair Work Done ❑ Type of Pump H:`P' R <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 501 n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION LJ DESTRUCTION L1 (No septic system permitted if public sewer is kvr� <br /> Installation will-serve: Residence JCCommercial <br /> within 200 feet.) r Commercial_ Other " <br /> Number of living units: ' Number of bedrooms - <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE' ❑ No. & Length of lines gg <br /> TotallengthYsize T I <br /> FILTER BED 0 Distance to nearest: Well Foundation ' 1 <br /> Property Line . <br /> S. <br /> SEEPAGE PITS " ❑' Depth ,r:__ Size.. 1 <br /> Number <br /> SUMPS ❑ Distance to nearest: Well 'Fp da{ion <br /> DISPOSAL PONDS ❑ 1 Rropertjr Line <br /> " <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-JoaquinLocal Health District. <br /> Home owner or licensed agent's signature certifiei 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 /> cettifies 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 applicant mus all for all re <br /> __ qui d inspec' ns. Complete drawing on reverse side. <br /> Signed X / <br /> Title: _ <br /> ,r - •-r—_ - - Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ,3 O I <br /> ~ Date � Area I <br /> Pit or Grout Inspectio <br /> Date^ Final Inspection by <br /> Date <br /> Additional Comments: <br /> ElStk 466-6781 ❑ Lodi 369- 1 ❑ Manteca%1 B23'7104 .- O-Tracy 38,5 <br /> 835=6 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,,P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO H RECEIVED BY /, DATE /PERMIT{NrO�, r <br /> + EH14-24(REV.iiAs) " T ��!(7 �,.,.CSCE O 1 t (�i����^� (; j--7 �.1(. <br /> -j;. EH 1428 V .. ..*�n+c_, l i t1 I <br />