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APPLICATION FOR PERMIT l� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,:STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <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 <br /> Cit ~� Lot Size PM <br /> Owner's Name �+ s Address 36 Z Phon <br /> Contractor f z_ 5 �'}}� �" ` <br /> Address"' License Ni-_��� 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 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE,WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE ROBLEM AREA CONSTRUCTION SPECT <br /> ❑ Industrial ❑ Open Bottomi ❑ Manteca xcavation `": _ Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casi Specifications r <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal `.��+' Type of Grout t <br /> ❑.Irrigation tox. Depth ❑ Eastern Surface Seal Installed,by <br /> Repair Work Don Type of Pump H.P. t State-Work Done _-- <br /> Wel action ❑ Well Diameter Sealing Material (top 50'1 I <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic,system,permitted if public sewer is <br /> -� -�- available•vviil in'200 feet./ <br /> Installation will serve: Residence ' Commercial— Other <br /> 1 <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/Mrfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 1 <br /> 1w• ' Method of Disposal <br /> Distance to nearest: Well Foundation PropertykLine <br /> ix <br /> LEACHING LINE ❑ No.:&-Length of lines r` Total length/size .. <br /> FILTER BED ❑ Distance to nearest: WellFoundation (= ----Property Line <br /> SEEPAGE PITS ❑ Depth- size Number��� i { <br /> SUMPS .,r ;.EJDistance to nearest: Well Foundation 4 Pr`bperty Line7 <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. { I f <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." 1 t <br /> The applicant must call for all re uired�inspections. Complete drawing on reverse so I <br /> f - <br /> Signed Title: , Date: ® <br /> i <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _Date_ "mow ? Area <br /> Pit or Grout Inspection by Date Final Inspection by �_ D 0o�� <br /> Additional Comments:o <�- <br /> _ Z <br /> j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104.;1 Ul-Tracy 835-fi3 `\ <br /> Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. 8o�2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> 1 EH 13-241REV.1 H513j `�� O� vIlk �(� 19'7-14141 — <br /> EH 14-28 <br />