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APPLICATION FOR PERMIT <br /> S OAQ -11'N LOCAL HEAL RfCT <br /> !' <br /> 1671!E. AZELTON AVE , STOC A <br /> ;I -6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED , <br /> (Complete in Triplicate) <br /> Application is hareby 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 _( Q r< Lot Size PM <br /> Owner's Narrle-_t1,11 Addresses Phnnrs0 Q o <br /> Contractor Address. + � License <br /> TYPE OF WELL/PUMP: 11 NEW,WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION" ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC•TANK ." v -SEWER LINES _ DISPOSAL-FLD. WE <br /> FOUNDATION AGRICULTURE WELL WELLF PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEWAREA_,,CQNST UCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation t Dia. of Well Casing <br /> i". r � <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> f'1 Public "'. Cl Other N*' n Delta �Depth of Grout Seal ° Type of Grout _ <br /> I I Irrigation 1' Approx. Depth [ I Eastarn Surface Seal Installed by------L— <br /> W <br /> y f T <br /> Repair Work Done -Type of Pump -- `. H.P. State WorkDone <br /> Well Dest on ❑ Well Diameter Sealing Material Itop 50') <br /> Aepth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW"INSTALLATION 11 REPAIRrADDITION 1-1"TD"ESTRUCTIO No septic system permitted if public sewer is <br /> . ivailable within 200 feet.) <br /> Installation will serve: -Residence 'Commercial' <br /> i Other a -- <br /> .Number of living units: Number of bedrooms f o <br /> Character of soil to a.depth of 3 feet: Water table depth r <br /> SEPTIC TANK EJ-I',' Capacity No. Compartments <br /> PKG."TREATMENT PLT. Cly✓ Method of Disposal n <br /> Distance to nearest: Well F6iindation Property Line r <br /> LEACHING LINE. ❑ No. & Length of lines k Total length/size <br /> FILTER BED Distance to nearest: " Well; Foundation Property Line <br /> f <br /> SEEPAGE PITS I I :Depth " Size Number <br /> SUMPS f�l�rDistance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 7i <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 /> cartifies the following: "I certify that in the performance of the work for which this permit is issued,.l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica ust call for all required in pections. Complete drawing on r rse. , <br /> Signed r .Title:" - d4[ <br /> Date: <br /> e FOR DEPARTMENT USE ONLY 1 r <br /> Application Accepted by Date �1 Area <br /> Pit or Grout.Inspection by vDaate fsppectionm6ffDat <br /> Additional Comments: AID q ew <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 95241 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT NO. <br /> ♦ EH 13-24 IREV. <br /> EH 14-28 �i1 r J. T -- _ P - ! �7'J - <br />