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P� 1 <br /> f <br /> k APPLICATION FOR PERMIT <br /> LTH DISTRICT <br /> SAN JOAQUIN LOCAL HEA ) {� <br /> r G J <br /> -�. 1601 E. HAZEL T ON AVE., STOGKTON, CA <br /> Telephone (209) 466-6781 ( <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED I <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. 1Y - <br /> Job Address ,A �- City Lot Size PM <br /> Owner's Name Address <br /> Contractor <br /> / Address p -E` icense NoPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑. DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL <br /> FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mant Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> M Public ED Other Cl Delta Depth of Gr`ou't Seal'"""""'-'"""'—"'""'-? Type of Grout <br /> ] Irrigation�.. _Approx, Depth l 1 Eastern Surface Seal Installed by ~ <br /> Repair Work Done Type of Pump H.P. r State Work Done' <br /> Well Desir n ' ❑�"yWell Diameter a,Sealing Material ltop 50'1 <br /> Tw "Depth - Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK`: NEW INSTALLATION I 1 REPAIR/ADDITION i-I DESTRUCTIO No septic system permitted if public sewer is `1 <br /> {" available within 200 feet.) <br /> Installation will serve: Residence_" Commercial_ Other !' i <br /> Number of living units: Number of bedrooms <br /> r <br /> i <br /> Character of soil to a depth of 3 feet: -- Water table depth ( <br /> SEPTIC TANK ❑ Type/Mfg „ Capacity No. Compartments i ~, <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> e <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundabori', Property Line <br /> SEEPAGE PITS l 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well t--foundation --- Property Line <br /> F <br /> DISPOSAL PONDS 0 <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: 'A 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." _ 4 <br /> The applicant muot call for ail required inspections. Complete drawing on�r yarse sid <br /> Signed X y Title: Date:67 _ t <br /> FOR DEPARTMENT USE ONLY " r <br /> � 11 <br /> Application Accepted by Date Area t <br /> Pit or Grout Inspection by Data Final inspection by Date — 'r" <br /> Additional Comments: r I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haz Iton Ave., P.O. Bax 2009, St ., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE APE;RM�17'NO.INFO CASH+ EH 13-241REV.by;Y " <br /> EH 14-2a <br />