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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT S <br /> 1641 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (249) 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. <br /> Job Address L <br /> ( f� � City `� Lot Size PM <br /> j Owner's Name Address _Z e�_,,r2J Phone �31� <br /> k <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM "DI <br /> REPAIR L3 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK�"`"�"�"� _SEWER `"—$"R LINESSPOSAL'-FLO. — LINE <br /> FOUNDATION AGRICULTURE WELL ELL PITSISUMPS. _ <br /> INTENDED USE i TYPE OF WELL PROBLEM AREA CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing <br /> I ❑ Domestic/Private D Gravel Pack Tracy - Type of Casing Specifications <br /> I f"1 Public !'— <br /> 0th ❑ Delta Depth of Grout Sea! Type of Grout _ <br /> I f inn alien _ A <br /> g' pprox. Depth ( I Eastern Surface Seal Installed by W <br /> R>Duction <br /> k D ❑ Type of Pump H.P. r State Work Done t 3 \ <br /> W ❑ Well Diameter Seafirig Material (top 50'1 r <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i -DESTRUCTION 1 INo septic system permitted if public sewer is <br /> _ available within 200 feet.) <br /> Installation will serve: 'Residence— Commercial— Other r <br /> Number of living units: Number of bedrooms <br /> Character of soil to aepth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg eG. r"I Capacity-__;_ No. Compartments I <br /> i PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE C. No. &Length of linesTotal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundatio'n'7 Property Line <br /> f <br /> o, <br /> SEEPAGE PITS DepthSize. _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t <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. , � — i I <br /> Home owner or licensed agent's si nature certifies g g es 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 Californi ' <br /> p a. '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 persons subjeci to workman's compensa- <br /> tion laws of California." 0 <br /> The a licant must call for all requi inspections. Complete drawing on reverse side. <br /> i <br /> Signed X 1�h - -. _Title: rf2`P+f/ Date: i <br /> zFOR DEPARTMENT USE ONLY `J1 <br /> Application Accepted by bate Area v <br /> Pit or Grout Inspection al Inspec <br /> ey` ...,..- �""�"`"" "/ �4C.r. pate�� ~Fintion by Date ; <br /> Additional Comments: 7�G 76_ 3 '"r -Or-P_4--4,j7.i ) <br /> © Stk 466-6781 ❑ Lodi 369-3621 Ll Manteca 823-7104 Trac 835-&-48t <br /> I ; <br /> c <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1[i01 E. Hazelton Ave., P.O. Box 2009, Stk., GA 952011 ` <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO DATE PERMIT'NO. <br /> . EH 13-24(REV.r i H 51 <br /> ER 14-28 � `] L� `cif"J D r <br />