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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT c? <br /> 1601 E. HAZELTON AVE., STOCKTON, CA o� r <br /> Telephone (209) 466-6781w ��,� <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 /> W Local Health District.' .O - k r <br /> J5,z,� � <br /> City Lot Size M <br /> Job Address <br /> , � 1� Phone <br /> Owner's Name Address tom_ - <br /> d <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELLIPU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ . OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P9-- <br /> FOUNDATION AGRICULTURE WELL OTHPLWEtC PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA;, CON STR SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> ...»; of Well Excavation. Dia. of Well Casing <br /> T e oYCasin ^" Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy j yp - g <br /> ❑ ether ❑ a Depth of Grout Seal Type of Grout <br /> ❑ Public — <br /> ❑ Irrigation ---Approx.. Dep ❑ Eastern �. I Surface:Seal Installed by <br /> Repair Work Done El Type of Pu 1 H.P. State Work Done <br /> ..Sealin Material (to 50'1 ,J <br /> Well Destruction ❑ Well Diameter 9 p <br /> Depth - Filler"Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is <br /> _ 1 available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK X Type/Mfgp Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total ler gthlsize <br /> FILTER BED 1-1 -Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size 9 Number <br /> SUMPS ❑ Distance to nearest:-. , Well- Foundation Property Line, <br /> DISPOSAL PONDS ❑ r f r _ - � .e ~' <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 /> I sed agent's sigature certifies the following: "I certify that in-the performance of the work for which this permit is issued, 1 shall not <br /> Home owner or lice.n nto become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> employ any person such manner nn <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 Calif nia." <br /> The applican st r,,alf for all required ins ions:Complete drawing on rrse side. . <br /> Signed X <br /> Title: ��, Date: <br /> FOR DEPARTMENT USE ONLYa <br /> Date '.L1 rt U... Area <br /> Applicatio Accepted by <br /> ut s <br /> Pit'or GroInpcti <br /> e <br /> Date Finan Inspection b Date 6— <br /> Additional Comments: <br /> LJ Stk 466-6781 Lodi_369-362 eca -7104❑ Mant0,'Traci 83rr !� <br /> Applicant- Return all copies to: Environmental Health'Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT.DUE AMOUNT REMITTED H <br /> INFO JL i <br /> '+ EH 1324 4REV.I/x 57 `� �v I Y . <br /> EH 14-28 <br />