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I <br /> j APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> 1 Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 7018 p <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 /> f Local Health District. /� <br /> h Job Address / d / ��TAs- (f <br /> • City Lot Size PM <br /> Owner's Names� �� 57i_- ddress r <br /> Phone <br /> 'Contractor F/ c� Address Sn "License No.-5'00,:7'0;/Ph,,��J <br /> TYPE OF W UMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> MP INSTALLATION ❑ SYSTEM REP�REI OTHER ❑DISTANCE TO NEAREST: SEP NK SEWER LINES ISPOSA `.� ROP. LINE <br /> THER-WErr PITS/SUMPS <br /> INTENDED USE TYPE OF WELL P EM AREA CONSTRU,GT[ONISPECIFICATIONS <br /> ❑.Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr cy of Casing Specifications <br /> I'1 Public L1 Other Delta Depth of Seal Type of Grout <br /> I I Irri6dtion ox. Depth I ] Eastern Surface Seal Insta d Q <br /> Repair Work pone ype of Pump <br /> H.P, State o ne_ V <br /> Well Dest ' n ❑ Well Diameter Sealing Material (top 501 ` <br /> Depth -t <br /> De /v <br /> p Filler M Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAI A OITI DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.)' <br /> Installation will serve: Re ' ence - CommercialY Other <br /> Number of living units: Number of bedroom ',..,, �•„ f t <br /> Character of soil to a depth of 3 feet: T Water table depth C/ <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT.PLT. ❑ _ Method of Disposal <br /> Distance to nearest: Well Foundation Propertyline 0 <br /> r4..A <br /> LEACHING LINE No. & Length of fines otal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation f Property Line <br /> SEEPAGE PITS I I Depth Z ! '_Size C7 Number b <br /> SUMPS Distance to nearest: `Wel! f- Foundation Property Line --_ _1L_ <br /> DISPOSAL PONDS '❑` .. v <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,Loca! Health District. <br /> Home owner or licensed agent's signature;certifies the following: "I certify—t <br /> hat <br /> that in the performance of the work for which this permit is issued, I shalt 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 /> F certifies the followin I certify that in the performance of the' ork for which this permit is issued, I shall employ persons,subject.to workman's compensa- <br /> tion laws of Califor ra. i. <br /> 'r t . 6 <br /> The{applican u II for a q.fired-i peLtinr3srComplet I drawing on rev rse ide. <br /> t <br /> Signed X <br /> " Title: - Date: <br /> 4 <br /> FOR DEPARTMENT USE ONLY ' <br /> 104 <br /> f <br /> Application Accepted by Date Area 3 <br /> Pit or Grout Inspection by Date' Final,Inspection In Date" <br /> i 4{ <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Marit ca i 823-7104 ❑ Tracy 835-6385 <br /> Applicant--Return all copies to:-Environmental HealthFPermitf/Services,1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> r <br /> INFO CASH <br /> s <br /> ♦ EH 13-24 IREV.1/951 <br />