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f <br /> 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 /> 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. /l�, •s.,. f ll / <br /> Job Address �" / 6 J City- v Lot Size PM 1 <br /> j Owner's Name dress �' Phone _ <br /> a {J�Ci _ b a Plione rZ +` i <br /> ' a <br /> Contractors Name <br /> License No. <br /> .TYPE OF WELLLPUMP: NEW WELL ❑ WELL REPLACEMENT:❑ DESTRUCTION ❑r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR'11 �5L "t� OTHER. ❑.t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD. 7 .PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL :PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS <br /> h f <br /> ❑ Industrial ❑:Open Bottom >De <br /> a ra. of Well Excavation Dia. of-Well Casing <br /> t <br /> f E l Domestic/Private ❑ Gravel Pack Type of Casing Specifications } <br /> II-Public ' 1 �ti ❑other Depth of Grout Seal Type of Grout <br /> ❑ Irrigaton { �: '�pprox. Depth ace Seal Installed by <br /> Repair Work Doe ❑ Type of Pump H.P. State Work Done I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 1 <br /> Depth Filler Material (Below 501 t ! <br /> a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIOM DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> r - ---- � available within 200 feet.) <br /> { Installation will serve: Residence/K Commercial_. Other � _ 1. I7 <br /> I Number of living units: Number of b0drooms <br /> } Character of soil to a depth of 3 feet: —Water table depth i <br /> SEPTIC TANK i ype/Mfg `+ rr Capacity' f�dl No. Compartments 2 <br /> PKG. TREATMENT PLT. ❑ �. t s Y t 0. vMethod of Disposal i <br /> w. � <br /> Dstance to ri es Welt w Foundation Property Line <br /> LEACHING LINE + No. & Length of lines P" ;Toth-length/size d� <br /> f fit. `- � <br /> FILTER BED ❑ Distance to nearest: f. 1Nell. Foundation Property Lina i <br /> i t <br /> SEEPAGE PITS El Depth I Sri Number f <br /> SUMPS ❑ Distance to'nearesty " Wel Foundation Property Line <br /> a 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 /> rules and regulations of the San Joaquin Local Health District. <br /> 4 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 su manner alto become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature 4 <br /> I certifies the followings' ce 4 thai,m the performance of the work for which this permit is issued,I shall employ,persons subject to workman's compensa- <br /> tion laws of Californi s <br /> ! The applicant mus sll all.re' irO'r ctions. Complete drawing on reverse side. i <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY �r <br /> i Application Accepted by Date Area b <br /> 'Pit or Grout Inspection by 1 �. - .,Date Final Inspection by aAlDate r �� <br /> +ditianal Comments: <br /> S,"tk 466-67$1 ❑ Lodi 36b-3621' ❑ W'i teca4823-7104Y.'a .123 Tracy 835-6385 <br /> 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 FiECEIVED BY DATE PERMIT"NO. <br /> ;ICASH <br /> IN <br /> 5-ou .-.; <br /> t I!J v f Z .r� <br />