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APPLICATION FOR PERMIT r_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> F� 1601 E. HAZEL T ON AVE., STOCKTON, CA r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATEISSUED <br /> f (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 /> Jab Address ` City Lot Size �o 0 n PM <br /> Owner's Name Ad <br /> dress¢ - <br /> Phone <br /> Contractor Address �""CJ'� `f License No.� �Phone � <br /> TYPE OF WELL/PUMP, " NEW'INELL ❑ �� WELL REPLACEMENT ❑ DESTRUCTION El ' J <br /> I �P,UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Off•, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '` DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELD OTHER WELL PiTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing I <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy TypeYof Casin <br /> 9 Specifications <br /> Cl Public Ll Other El Delta Depth of Grout Seal T of Grout <br /> Type L1 Irrigation <br /> -L—Approx. Depth ❑ Eastern ' Surface Seal Installed by t T <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Wel! Destruction .❑ Well Diameter Sealing Material {top 501 }S�} <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REP,9113/A TION IC-2DES RUCTI N ❑ fNo septic system permitted.if public sewer is <br /> �1/J available within 200 feet.) € <br /> Installation will serve: Residence_ Commercial ,Other '«� 4•. 1� <br /> Number of living•units: Number of bedrooms I ~ <br /> Character of soil to a depth'of 3 feet: F"— ? Water table;depth <br /> SEPTIC TANKElType/Mfg. . I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> # Distance to nearest: Well s Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines 1 ¢ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number 1 <br /> SUMPS ❑ Distance to nearest: Well Foundation .P•roperty.Line.-Y�_, <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 4 <br /> " rtify that in the performance of the work for which this permit is.issued, I shat!not i <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: ture <br /> "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject u workman's compensa- <br /> The applica must call fo all requied inspections. Complete drawing on reverse side. t <br /> Signed Title: <br /> _ Date:„ � <br /> • <br /> FOR DEPARTMENT USE ONLY r i <br /> Application Accepted by DateArea <br /> f <br /> Pit or Grout Inspection b Date Final Inspection by Date t'_.” C• <br /> Additional Comments: <br /> ❑ Stk 466-6781 ? ❑ Lodi 369-3621 ❑ Manteca_823-7104 _ ❑_Tracy835-6385 <br /> Applicant- Return all copies to: Envirorimentel HHealth Permit/Se_rvices'1601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201 , <br /> FEE AMOUNTDUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. '- <br /> INFO CASH <br /> + EH 13.24(REV.1/0 s) <br /> EHf428 g-7 <br /> • s <br />