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' I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i 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 f 6 Y z a'J i <br /> City Lot Size PM <br /> OwnerF�y <br /> ' <br /> s Name C�� D Address �� 71VM cfi / Phone <br /> Contractor Address Zxw r License fVo��9�/d ��! J <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP FLD. PROP. LINE s <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Ileca ia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications <br /> f 3 Public n Other [� Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. De Depth astern <br /> P Surface Seal Installed by <br /> Rgpair'Work Done �O Type of Pump <br /> H.P. State Work Done <br /> Well Destruction �'v CJ Well Diameter 1 <br /> f Sealing,lUleterial (top 50'1 <br /> DepthFiller Materia! {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I y REPAIR/ADDITION-(I DESTRUCTION iNa'septic system per if public sewer is <br /> available within 200 feet.)% <br /> Installation will serve: Residence) Commercial_ Other f �- <br /> Number-of living units:- Number of bedrooms �"` <br /> Character of soil to a_depth of 3 feet: <br /> Water table depth i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 171 <br /> Method of Disposal <br /> Distance to nearest: Well Foundation��f : <br /> f Y ,Property Line <br /> LEACHING LINE Cj No & ; ,� <br /> i t Length of lines ' <br /> Total length/size i <br /> FILTER BED ( i ❑, Distance to nearest: 49Nelf. Foundation.`'• s Property Line l " <br /> r <br /> _4 <br /> SEEPAGE PITS I I Depth, Size Number <br /> 5UMPS— '�L-�—Distance to nearest:-Well -Foundation-J -- Property Line. t <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 r <br /> employ any person in such manner as to become subject to workman's compensation laws of Cafifornia."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permitisissued,t-shall emp <br /> tion laws of California." kfy.persons subject to workman's compensa <br /> The applicant mus call for all requir d inspe ct ions. Complete drawing on reverse -de. <br /> Signed X Date: <br /> Title: <br /> . <br /> FPARTMNT US�ONLY <br /> EApplication Accepted by OR DE7 <br /> } <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: � �4� � <br /> ❑ Stk 466-6781 ❑ Lodi 369,3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1t <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 1 <br /> a <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 41 <br /> INFO CASH RECEIVED BY PATE PERMIT'NO. <br /> +.EH 13-24[REV,t i H 51 <br /> EH 14-29 X Y <br /> t <br />