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{ a <br /> S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> t PERMIT EXPIRES TYEAR FROM DATE ISSUED / f <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 nqa5' e city of Size 'PM <br /> Owner's NameJt.11.lJ <br /> Contractor Address" License No. Phe <br /> TYPE OF WELL/PUMP: .NEW LL ❑ WELL R PLACEMENT 11 DESTRUCTION Ll <br /> l PUMP INSTALLATIO ❑ x, STEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST:w SEPTIC TANK SEWER L S DISPOSAL FLD. 'PROP. LINE <br /> ' FOUNDATION AGRI LTURE WELL. OTHER WELL - PITS/SUMPS G <br /> INTENDED USE i TYPE OF WELL PROBL AREA CONSTRUCTION.SPECIFICATIONS <br /> EI Industrial El Open Bottom ❑ to Dia. of Well Excavation Dia. of Well Casing �} <br /> ❑ Domestic/Private ❑ Gravel Pack racy of Casing Specifications <br /> f M Public ❑ Other 71 Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation _-"Approx. D th { I Eastern riace Seal Installed by <br /> i Repair Work Done ❑ Type of Pum H.P. f State Work Done _ V <br /> Well Destruction ❑ Well Diam er Sealing Material {top 50'1 <br /> Depth Filler Material (Below 501 r <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION I] REPAIR/ADDITION l 1 DESTRUCTION- (No septic system permitted if public sewer is V <br /> t vailable within 200 feet./ <br /> # Installation will serve: Residence_ Commercial— Other ~i <br /> Number of living units: Number of bedrooms y r qUt <br /> Character of soil to a depth of 3 feet: 1 Water table depth f L <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �cc <br /> PKG. TREATMENT PLT. ❑ _ Method of Disposal G <br /> Distance:.to nearest: Well Foundation Property Line ` <br /> � A f <br /> LEACHING LINE ❑I<No. & Length of lines Total length/size <br /> Y FILTER BED El 4 Distance to nearest: Well Foundation Property Line <br /> E <br /> e d f - <br /> SEEPAGE PITS 1*1 I Depth' Size Number <br /> SUMPS _ t ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ` ❑ s <br /> I hereby certify that I have prepared this application and that the work will be done in accor'danc'e 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 laws of California." <br /> The applicant must call for all require nspections. Complete drawing on reverse side. <br /> ,, r — <br /> Signed X ( �. [(/�/ Title: - Date: <br /> FOR`t)EPARTMENT USE ONLY 'A. <br /> .Application Accepted by date � � Area (J <br /> Pit or Grout Inspection y Date Final Inspection by �fr� Cknc � Dat wp <br /> 4 5 c' <br /> Additional Comments: rL -f—i <br /> ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 / !o ; <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> r <br /> INFO s AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO, <br /> a EH 13-241REV.1/x51 "[ i�� ���OQ j yti t �✓ 4'� (��„3�]� <br /> "E H 14-26 L,f• �+ [[[ -0 Ij M <br />