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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT -. <br /> p' 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 /> Job Address 4- v `� �� P u v City/" Lot Size PM <br /> Owner's Name ��i� "� Adress o/' T� ce�� . � �P L4 Phone <br /> Contractor✓ Address License No. one <br /> 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. <br /> FOUNDATION AGRICULTURE WELL OT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> n Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation pprox. Depth l I Eastern Surface Seal Installed by _ <br /> Repair Work Done Type of Pump H.P. State Work Done_ 00 <br /> Well Destr ' n ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO 1 (No 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 /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS O 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 laws of California." <br /> The licant must call for r p r�ednins s. Complete drawing onnrr"e�jverse side. f� <br /> Signed X >r'��'C� ' �� 'C r Title: V -Q-'L Date: 1 O <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date_27 - 27-164- Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: YAC <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M ca 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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE ///���,,,,,, PERMIT N/O. <br /> + EH 13-241REV.1/85) C+O \ �� / -22-_P <br /> EH 14-2e cjo 4 / t <br />