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ms's <br /> APPLICATION,FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 '` <br /> ' PERMIT EXPIRES 11-YEAR FROM-.DATE ISSUED <br /> j (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 /> Jab Address 3; < City lot Size PM <br /> Owner's Name ddress [ Phone <br /> i Contractor Address License No. Phone <br /> f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> s <br /> INTENDED USE TYPE OF WEL <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Ria. of Well Casing IZ <br /> ❑ Domestic/Private ❑ Gravel Pack acy Type of Casing Speci Ica <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout –{�{ <br /> F ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> F Well Destru ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION KNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> s <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 /> d PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <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 ❑ .6- <br /> I <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 /> f' 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 required inspections. Complete drawing on reverse side. <br /> i <br /> Title: f �(�%ff/�' Date: <br /> l , <br /> F D PARTMENT USE ONLY <br /> f <br /> Application Accepted by Date �"lJ-� Area C � , <br /> Pit or Grout Inspection by ? Date Final Inspection by c__ Date10 <br /> Additional Comments: �'' Vc� ��✓'s3 t` �� �d ,7 L���o � u�� �a 6► ��/ � <br /> ❑ 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, Stk., CA 95201 <br /> FEEi <br /> INFO AMOUNT DUE AMOUNT REMITTED ' CAS RECEIVED BY DATE PERMIT'NO. <br /> .41- 00 <br /> + EH 13-241REV.1/951 <br /> EH 14-28 <br />