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` APPLICATION FOR PERMIT <br /> t _ <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 9601 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 /> made in compliiance.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 741 <br /> City Lot Size PM <br /> Owner's Name Address / Phone <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> k PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER ❑ <br /> y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INT NDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Ind trial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dia. of Well Casin <br /> ❑.Do estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SpecificafOons <br /> ❑?Pub c ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> p Irrig tion ---Approx. Depth ❑ Eastern Surface eal Installed by <br /> Repair ork Done ❑ Type of Pump H,p, <br /> State Work Done <br /> Well struction ❑ Well Diameter Seali M erial It p 501 <br /> Depth atei al (Bel 50') <br /> TYPE F SEPTIC WORK: NEW INST:L,�- <br /> TIOIiI ❑ ,�1 DIT D,{ TRUC ON ❑ (No septics em permitted if publi sewer is <br /> t a' Ian in 200 feet.) <br /> Inst potion will serve: Residence_ ommercial i Ot r ���'TTT"' /"� <br /> Nu ber of living units: ber of be ooms? f <br /> b s <br /> Cha acter of soil to a depth of 3 Water table depth <br /> SEPTI TANK <br /> / Type/ f pacity No. Compartments <br /> `PKG. REATMENT PLT. ❑ <br /> 4 Method of Disposal <br /> W Dista ne t: INe oundation Property Line <br /> LEAC flNG LINE No LeW6pr } <br /> -.� Total length/size <br /> FILTE I BED L� D t ce,to ne r F ndation Property Line <br /> SEEP GE PITS ❑ Deet`;`�'�'S¢ Number <br /> SUM S ❑ Distance` o eai `st "' f ei Property Line <br /> DISPOSAL PONDS ❑ i :; ".: <br /> I here y certify that i have prepared thisiap c `tion aLorkork will be done in accordance ith San Joaquin county ordinances, st a laws, and <br /> rules nd regulations of the San Joaquin Lo I HealthHorn owner or licensed agent's ignature certifies the certify that in the performance f the work for which this permit is issu , 1 shall not <br /> empl any person in such mannas tv become subjen's compensation laws of Califo nia."Contractor's hiring or sub-contract g signature <br /> certifi s the fallowing:"I certify t in the performancefor which this permit is issued,I hall employ persons subject tv workman' compensa tion I of California."The plicant m st call for all re r tions. Coin on reverse side." y; <br /> Signe <br /> A Title: Date: <br /> ,."• h. FOR ARTMENT USE O Y <br /> Appli ation Acceptedby =' ¢ <br /> Datev Area <br /> Pit or Grout Inspection by Date Final Inspection by Dat 0 P <br /> Additi nal Comments: <br /> ❑ St 466 6781 d Lodi 369 3621 El Manteca '823-7104 Cl Tracy 835-6385 <br /> Appli ant- 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 <br /> INFO {� CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24 iREV.1/957 '/y� �� p•�, � � y� <br /> EH 1426 `(J S-(f / _ <br />