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APPLICATION FOR PERMIT �d <br /> �J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />` 1601 E. HAZELLiON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br /> s: (Complete in Triplicate) <br /> L:I?' <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. E <br /> Job Address �' City 5hbL-bkA Lot Size 111 ,X 4-7/ PM <br /> I <br /> Owner's Name n Y�r L , Ae Ir <br /> ddress ; —"-tom D , Phone 72 0Q r <br /> Contractor '-F Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ E-Er UCTION ❑ <br /> k PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTUR L OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PRPr <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Dia. of Well Excavation Dia. of Well Casing ICK <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ox. Depth C1 Eastern Surface Seal Installed by <br /> i r <br /> Repair Work Done ❑ pe of Pump H.P. State Work Dane <br /> 1 Well Destruction L3 ell Diameter Sealing Material (top 501 <br /> 1 Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION V(No septic system permitted if public sewer is <br /> ailable within 200 feet.) <br /> k <br /> Installation will serve: Residence Commercial Other <br /> Number of living units:_L__ Number of bedrooms] <br /> ' Water table depth <br /> Character of soil to a depth of 3 feet: P <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well 'Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth ) Size Number <br /> SUMPS ❑ 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 /> I 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 compense- <br /> tion laws of California." 'l <br /> .t <br /> The appTitle: Date: <br /> li must c II otr all required inspections. Complete drawing on reverse side. <br /> Signed I <br /> Sor= 14-i -`67 <br /> FOR DEPARTMENT USE ONLY <br /> f Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final spection by u-'�"'--�r Date <br /> Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 3WN21 ❑ Man eca^823-7104 ❑ Tracy 835-8385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> { i) <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24(REV.I/s51 <br /> + EH 14-28 Y <br /> , t i <br />