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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRIC �[ <br /> 1601 E. HAZELTON AVE., STOCKTON, C � ij Telephone (209) 466-67$PERMIT EXPIRES 1YEAR FROM DATE ISSUED A <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. �j- <br /> V Job Address Z 2 E/� City.-/ <br /> Lot Size d PM <br /> /P//l� <br /> Owner's Name Address • u ,- Phone L <br /> �: <br /> �r�! - <br /> I CLicense No. Phone <br /> Contractor Address _ <br /> I <br /> i TYPE-;OF WELL/ NEW WELL ❑ WELL REPLACEMENT{❑ DESTRUCTION ❑ <br /> STALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION LTURE WELL 0 ITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR03LEM UCTION SPECIFICATIONS <br /> ,a" El ❑ Open Bottom anteca Dia. of Well tion Dia. of Well Casing <br /> � <br /> ❑ Domestic/Private ❑ Grav [I Tracy Type of Casing Specifications <br /> FI Public ther ❑ Delta Depth of Grout Seal Type of Grout <br /> r i I Irrigation -Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done Ll Type of Pump Ft.P. State Work Done <br /> Well Destruction ❑ Well Diameter-,--- .Sealing Material_ftop-501. — -- <br /> r - Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION l I DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) - <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 /> hc, <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Weil Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> y SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared.this-application and that the.wo_rk will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Dil%trict. } "c - ­_ " .---- <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 of sub-contracting signature <br /> certifies the following: "I certify that in the performance of thk for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must I�ra <br /> aired inspections. Complete drawing on reverse side. <br /> Signed X� Title: Date: vs� CJ <br /> FOR.-DEPARTMENT USE ONLY y( <br /> Application Accepted by Date �2 �� Area l <br /> s Pit or Grout Inspection Date Final inspection by Date ✓ <br /> T4� <br /> r C4a./zy 6t.vai-_ er+r <br /> r ,Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> +, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED R RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> ' �--7 <br /> +.EH73-24IREV.iin51 / # 'Z <br /> 4 EH 14-2e �J <br />