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,f. 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. <br /> Job Address Lot Size PM <br /> �r�x/ d - <br /> f !/ S :�/�fT7�t Phone <br /> Owner's Name V� � Address � ��� <br /> -­1 (407-14X-3c)c) <br /> Contractor OL�) ►>,d.C.rc e AJt� Address License No_. -J Phone <br /> TYPE OF WE :PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION RICULTURE WELL OTHER WELL PS.- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA SPECIFICATIONS <br /> Ll industrial L1Open Bottom ca Dia. of a avation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gr ❑ Tracy Type of Casing Specifications <br /> [-I Public 1-1Other FlDelta Depth of Grout Seal Type of Grout <br /> I I Irrigation _-Apprcx. Depth l I Eastern Surface Seal Installed by- <br /> Repair <br /> y Repair Work Done ❑ Type of Pump H.P. State Work Dane _ {' <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION l 1 DESTRUCTIO No septic system permitted if public sewer is <br /> ailable within 200 feet.► <br /> r <br /> Installation will serve: Residence_ _ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ` <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth Size Number <br /> SUMPS ❑ 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 /> 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 of California." <br /> The applican must call for all required inspection Complete drawing on reverse side. <br /> Signed ` Title: .. t Date: r r 2--Z— <br /> Signed <br /> Z �U <br /> l _ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Z Area <br /> Pit or Grout Inspectiy Date Final Inspe r��++ - Date <br /> Additionei Comments: 0, 64,1"-w r_/-,1( <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Trac -6385 1,4t- <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., 1 95201 <br /> IIts-fg3 fq 2,6 3 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �+ <br /> INFO l <br /> +.EH 13-241REV.t/H51 � 35� <br /> EH c1-28 <br />