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4- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.LYON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> z {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. �-y� <br /> Job Address / � � �il�G�� /yl�G Ci SUP �:7 y X1127 PNI <br /> c �d��l�. �i ty���� Lot Size--- <br /> r <br /> Owni <br /> s Name Address ,1 Phone <br /> Contractor Addremi . License Nl�PP 3��Phonec_� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT E W OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Excavation Dia. of Well Casing <br /> E] Domestic/Private ❑ Gravel Pack Llcy Type of Casing Specifications <br /> ❑ Public ❑ Other C1 Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done 4 t <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 <br /> Depth Filler Material {Below 501 V <br /> TYPE OF SEPTIC WORK:: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic'system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other 4� (/ <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 /> s <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS d Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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."Contractors 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 C ornia." <br /> The <br /> ,pp <br /> ust call for all re <br /> suadinspections. Complete awing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byT Date '10`g Area <br /> Pit or Grout Inspection by Da Final Inspection by Date <br /> l Additional Comments: ro- i ` ous <br /> r -7 b4 C <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. Bax 2009, Stk., CA 85201 <br /> IEEENFO AMOUNT DUE AMOUNT REMITTER CASH RECEIVED BY DATE PERMIT NO. <br /> ___J <br /> EH 13-241REV.t/951 7 175— C� 191 <br /> EH 1428 j� <br /> s <br />