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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I` 1601 E. HAZELTON AVE., STOCKTON, CA , �p�� <br /> I! 'Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 /> Local Health District. <br /> Job Address �:. 2 T� rr City S`xc%?orf Lot Size 76X33 C PM <br /> Owner's Name �` a r ddress � , <br /> I` - Phone <br /> Contractor Address _ License No. Phone - <br /> TYPE OF WELL/PUMP: it NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI S DISPOSAL FLD. PROP. LINE <br /> FOUNDATION' AGRICULTU WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON RUCTION SPECIFIC <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of II Excav Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of g Specifications <br /> ❑ Public ❑ Other E-1 Delta D of Grou eal Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Ins d by <br /> Repair Work Done ❑ Type'h f Pump P. ----r State Work Done <br /> f <br /> Well Destruction ❑ Well Diameter - Sealing Material+.ltop 50'1 <br /> Depth Filler Material (Below 501) I <br /> TYPE OF SEPTIC WORK: NEW INSTAL ION d REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial_ Other r <br /> 'available within 200 feet.) <br /> Number of living units: -•F Number of bedrooms <br /> Character of soil to a depth of�3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE Na. & Length of lines Total length/size <br /> c <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PiTS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sari 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: ` <br /> 9 t g g: "1 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 /> n of Caiffornia." <br /> The pplican ust cal for all ra�,Kired,46ctions. Complete drawing on reverse side, r� <br /> Signed r ' Title: 13 <br /> i Date: <br /> FOR DEPARTMENT USE ONLY 4 f <br /> c Accepted by Date s \� Area <br /> Pit or Grout Inspection b DateFinal Inspection by pie ��( <br /> Additional Comments: �N - <br /> ❑ 5tk 4W6781 ❑ Lodi `1369-3621 ❑ eca 823-7104 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Stk., A 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PER N0. <br /> If <br /> + EH 13-24[REV.1 8 51 ,� C>L) s <br /> EH 1418 (( � / <br />