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APPLICATION FOR PERMIT U 3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 /> Local Health District. <br /> '/ <br /> Job Address ,A ql+r- /7 City Lot Size PM <br /> Owner's Name d/3AA)A1 k/A LR S Address i�r�O 5..4JLC 1 `N+- � �)V�Phone �� � -3 <br /> Contractor Address License No. Phone <br /> TYPE OF W /PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU.CTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO 14EARES . EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOU TION AGRICULTU L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF W PROBL EA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel P ❑ Trac Type of Casing Specifications <br /> ❑ Public ❑ r ❑ Delta epth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Su a eal Installed by <br /> Repair Work D ❑ Type of Pump H.P. State Work Done <br /> Well uction ❑ Well Diameter Sealing Material (top 50') O <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic sys-tenkpermitted if public sewer is <br /> vailable within 200 t.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: 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 /> LEACHING LINE ❑ No. & Length of lines Total length/size b <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line tA <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 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 law=1nspecti ;;DatFe_ <br /> f Clifi " <br /> The appreqections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> ApplicatDate a: Area d3 <br /> Pit or GDate Final Inspection by Date <br /> Additional Comments: 'A� l I4 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Zff Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/ServicesA601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> �7 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.1/e s) <br /> EH 1428 <br />