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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 two <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> . (Complete in Triplicate) <br /> i 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. ;,,;14. <br /> Job Address +° r'` City Lot Size PM <br /> ! ](t i� 4eENA.. CZ Address a0j5 iv_ `_ <br /> Owner's Name ISL Phone— <br /> f <br /> Contractor y Address License No. Phone <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE --�� <br /> DISTANCE TON T: SEPTIC TANK SEWER LINES DISPOS PROP. LINE <br /> F TION AGRICULTURE WELL — HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL OBLEM AREA RUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing <br /> ❑ <br /> Domestic/Private ❑ Gravel Pack racy Type ing Specifications <br /> r O Public ❑ Other ❑ Delta Depth of Grout a Type of Grout <br /> ❑ Irrigation. pprox. Depth ❑ Eastern Surface Seal Installed by �l <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Dest Ion ❑ Well Diameter Sealing Material (top 501 r <br /> Depth ----Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION .(No septic system permitted if public sewer is – <br /> . ` - ` - : '` available within 200 feet.) <br /> Installation will serve: Residence 4— Commercial_ Other <br /> Number of living units: ' { <br /> _�_ Number of bedrooms� f <br /> Character of soil to a depth of 3 feet: f Water table depth <br /> SEPTIC TANK Type/Mfg FCapacity a No. Compartments <br /> PKG. TREATMENT PLT. ❑ f t , MetKod of Disposal <br /> Distance to nearest: Well 'Foundation Property Line <br /> ,4 LEACHING LINE ❑ No. 81 Length of lines Total length/size <br /> r FILTER BED ❑' Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> I SUMPS ❑ Distance to nearest: Well I Foundation Property Line <br /> i DISPOSAL PONDS ❑ # 1 <br /> I hereby certify that 1 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." r' <br /> The applicant ust call for all req 'ed inspec' ns. Complete drawing on reverse s�ide. I �y <br /> Signed Title: r r { Date: 3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date RArea 0", <br /> Pit or Grout Inspection Date ' r Final Inspection by- Dater--1 z <br /> Additional Comments: D/� ��� k-"`�� d <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 '❑ Tracy 835-6385 t "'` �Y Y t Y►' ,4 i U <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952ol <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 'N <br /> H RECEIVED BY DATE PERMIT' O. <br /> INFO p� /�q <br /> + EN 3-24{REV-1185) � v� `J���� � a � l�-�7 <br /> EH 14-28 <br />