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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160.1 E. HAZETON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> f k CJob Address O City Lot Size PM <br /> ✓G7✓d <br /> Owner's Name Address Phone ?V&-los <br /> VL <br /> Contractor! 'ss - License No.��OPhone ',/2 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ✓ <br /> PL11iAP INSTALLATION'❑ 'Sy -R-EPA'IR'-Cl OTHER-8---- >� <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LIN DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRIC URE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS t <br /> ❑ industrial ❑ Open Bottom ❑ Mantec Dia. of Wali Excavation Dia. of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> M PublicN ❑ Other ❑ D to Depth of Grout Seal Type of Grout _ <br /> I I Irrigation --Approx—Depth.».,[-1 astern—_ Surface Seal Installed by � t <br /> Repair Work Done ❑ Type of Pump H,P r State Work Done <br /> Well Destruction ❑l Well Diameter Sealing Material (top 501 <br /> �� } <br /> 4 f Depth *� ; Filler Material 18olow 50'1 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i;l REPAIR/ADDITION i I DES UCTIONRSI (No septic stem permitted if public sewer is O <br /> I.. able hin 200 feet.) <br /> Installation will serve:a Residence_ Commercial_ Other � � _ <br /> Number of living units:TY Number of bedrooms <br /> Vk <br /> Character of soil to,a depth of 3 feet: Water le dtA')-t4 <br /> r - <br /> SEPTIC TANK .">'0. Type/.Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �. <br /> , I Method of Disposal <br /> Qistance-to nearest: Well FoundationProperty Line <br /> E , <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well F dation Property Line <br /> � a <br /> SEEPAGE PITS I 1 Depth '-Size _ Number F <br /> SUMPS ❑ Distance to nearest: - Well Foundation Property Line —= t <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and t t the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules and regulations of the San Joaquin Local Health frit[. = 1 <br /> Nome owner or licensed agent's signature certifies the.: <br /> ollowing: "1 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 th8,p rtarmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica muKcall f equirod i pections. Complete drawing on reverse side. 3 <br /> Signed X <br /> .Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> G"} � <br /> Application Accepted by Dace Area <br /> Pit or Grout Inspection by / Date / Final Inspection by ) Date <br /> Additional Comments: lin'►^ �Pb p j6j D t <br /> i <br /> ❑ Stk 466-6781 EJLodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-6385 t <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> FEE ' <br /> INFO p MOUNT-DUE 4AMOUNT_BEMITTEO_ _ AECEIVEp-BYE- _DATE+*. PERMIT'N0. <br /> +.EH 13-24(REV.1/H 5) �t N <br /> EH 14-28 <br /> O <br /> ( <br />