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APPLICATION FOR PERMIT { <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT .40 ,OeAl <br /> 1601 E. FI.AZEL T ON 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. ,�i�.Da �•+'+< <br /> Job Address a City Lot Size PM <br /> Owner's Name Addresses Phone 9�lj C <br /> r (cense IVo.[ U r Phone ! C �'- J"P92, <br /> Contractor Address <br /> TYPE OF WELL-/PUMP: --NEW EL-L_D—,—_­WELL—REP•L-AC ME-N�®—DEST}3UCTJON...O..,_j. ,' <br /> PUMP INSTALLATION ❑ SYS REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:,SEPTIC TANK EWER LIN DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A RICU RE WELL OTHER WELL PITSISUMPS <br /> PR <br /> OF WELL: <br /> OBLE INTENDED USE t_TYPEOBLEEA CONSTRUCTION SPECIFICATIONS r r i <br /> El Industrial El Open Bottom D M ec Dia. of Well Excavation Dia. of Well Casing , <br /> GJ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> l`l Public 171 Other t�-�- - Delta Depth of Graut Seal Type of Grout <br /> I I Irrigation` Approx. De I I Eastern Surface Seal Installed by - CA <br /> Repair Work Done" 0 Type of Pump H. . State.Work Done 1 <br /> Well Destruction., ❑ Well Diameter Se ing Material (top 501 <br /> r � <br /> } <br /> \ Depth # Fill Material 113e1ow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIIDN I 1 ESTRUCTION K (No septic system permitted if public sewer is <br /> 47 <br /> Installation will serve: Residence_ Commercial_ Other <br /> k) avail le within 200 feet.) <br /> i <br /> Number of living units: Number of bedrooms <br /> �S� at <br /> Character of soil to a depth of 3 feet: Gab d p <br /> SEPTIC TANK ❑ Type/Mfg apacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal - <br /> Distance to nearest: Well' Foundation Property.Line <br /> LEACHING LINE ❑ No. & Lengthxof lines Total length/size " <br /> } <br /> FILTER BED ❑ Distance to nearest: " Well Foundation P-roperty_Line_r <br /> SEEPAGE PITS i l Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> 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 /> E rules and regulations of the San Joaquin Local 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, 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 /> certifies 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 oUCalifornia." `. <br /> i <br /> The applicant ust call for all r red inspe ions. Complete drawing an reverse side. ' <br />' Signed X t Title: Date: <br /> .r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area ►�i`f <br /> Pit or Grout Inspection by Date Final Inspection by_ E Date `r i t <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTEDRECEIVEDRECEIVEp BY DATE PERMIT'NO. <br /> INFO <br /> +.EH13-241REV.I/N5]so <br /> + EH 14-T8 <br /> �. <br />