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APPLICATION FOR PERMIT <br /> �✓ SAN JOAGUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE,, STOCKTON, CA � y <br /> Telephone (209) 466.6781 <br /> j 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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pum and the described.This application is <br /> I: Local Health District. p Rules and Regulations of the San Joaquin <br /> Job Address <br /> "City Lot Size PM <br /> Owner's Name _- Address � � y <br /> / – Phone y <br /> _ i <br /> Contractor Address <br /> TYPE OF WELL/PUMP: License No. phone ✓� <br /> N�VII WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ <br /> DISTAN NEAREST: SEPTIC TANK OTHER Q <br /> SEWER LINES OSAL FLD. <br /> FOUNDATION AGRICULTUREPROP. LINE <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYP LL PROBLE CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Q Open Bottom nteca <br /> El Domestic/Private Cl Gravel Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Public ❑ Tracy Typasing <br /> g <br /> titer - Q Delta e of CSpecifications <br /> Dep rout Seal Type of Grout_Irrigation —Approx. Depth ❑ Eastern <br /> Surface Seal Ins by <br /> ork Done ❑ Type;of Pump H.P. <br /> Well Destruction ❑ Well DiameterState Work Done <br /> Sealing Material (top 501} <br /> Depth Filler Material {Below 501) <br /> TYPE OF SEPTIC WORK: ;NEW INSTALLATION ❑'. REPAWADDITION ❑ DESTRUCTION (No septic system <br /> `* permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other avails le within 200 eet.) <br /> Number of living units: Number of bedrooms A• _ � `J <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC'TANKType/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> ` Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line , <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED Total length/size <br /> Q Distance to nearest: Well Foundation <br /> Property Line— <br /> SEEPAGE PITS Depth '-Size <br /> Number <br /> ❑ Distance to nearest: Well Foundation ;f <br /> DISPOSAL PONDS p Property Line <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 Locaf'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, f 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 /> certifies the following:"I certify that in the performance of the work for which this,permit is issued,'I shall employ Per subject to workman's compensa- <br /> tion laws of Cal' nia." <br /> The applica ust call for all r ire sections. Complete drawing on reverse side. j <br /> Signed <br /> Title: _ Date: <br /> FOR DEPARTMENT USE ONLY, <br /> Application Accepted bFLodi3W3621 <br /> _ rti <br /> Date d� Area <br /> Pit or Grout InspectionDate <br /> Final Inspection by. Da <br /> Additional Comments: 9 'E <br /> Q Stk 466-6781 ❑ anteca 8x3-7104_ ❑ Tracy 8358385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 55201 <br /> FEE G� <br /> INFO AMOUNT DUE AMOUNT REMITTED ,' CASH RECEIVED BY :- DATE <br /> W r PERMIT'NO. <br /> + <br /> EH 13-74 IflEY.F/a 51 L � -�� ���f E � ^��Q" i <br /> EH 1426 i.J `'f1 S. ^2-7 'g7^J" F <br />