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APPLICATION4FOR PERMIT •: b <br /> SAN JOAQUIN-LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> F ufT >F� _t(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 /> Jab Address <br /> City-:2>CD. ' !. tiy. 3F <br /> Size: PM <br /> bwner's Namet <br /> _Phone <br /> Contractor Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> r - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DATION AGRICULTURE WELL OTHER <br /> WELL—PITS/SUMPS <br /> INTENDED USE 2TYPE OF WELL LEMAREA CONSTRUCTION SPE <br /> ❑ Industrial LJ Open Bottom ❑ Manteca ia. xcavation Dia. of Well Casing <br /> ED Domestic/Private F] Gravel Pack F1 Trac Type of a Specifications <br /> ❑ Public ❑ Other Delta Depth of Grout Seal . ' <br /> Type off Grout <br /> ❑ Irrigation Depth ❑ Eastern Surface Seal Installed by ' <br /> Repair Work Done Type of Pump H.P. State D Work-b__ _ <br /> Well ction Ll Diameter Sealing Material (top 50') <br /> II Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms r ; <br /> Character of soil to a depthof3 feet:�I <br /> Water table.depth <br /> SEPTIC TANK ❑ Type/Mfg 1 Capacity f No. Compartments` <br /> PKG. TREATMENT PLT. ❑ .Method of Disposal <br /> � <br /> Distance to nearest: Well Foundation f ?Property Line - <br /> LEACHING LINE ❑ No. &'Length of lines _ /` ! Total length/size \ n <br /> FILTER BED. ❑ Distance to nearest: Well Foundation ` - <br /> Property�Line— - <br /> i .. s S� <br /> SEEPAGE PITS ❑ depthk� Size v�- � - <br /> Number <br /> SUMPS ❑ .Distance td nearest: Well Foundation Property Line <br /> ,_ <br /> DISPOSAL PONDS <br /> ❑ "�"=`...:a l �� -� ,� •tet :•� _,.'� t.� — <br /> . c , <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 1 <br /> certifies the following; "I cert <br /> t in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws f California." <br /> The applica ust cal r squired inspections. CompI699 dr ing on reverse sid . <br /> Signed 3 <br /> Date: �, 20 <br /> FOR DEPARTMENT U O Y <br /> Application Accepte { Date Area 0 <br /> Pit or Grout Inspection by ! Date Final In ction by Date <br /> Additional Comments: s' <br /> ❑ Stk 466-6761 odi 369 362] ❑ Tracy- 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. ox 2009, Stk., CA 95201 <br /> �CJMn�t, �3.7.104 <br /> } <br /> FEE AMOUNT DUE !! AMOUNT REMITTED CK I <br /> INFO RECEIVED BY DATE PERMIT'NO. <br /> a EH 13-24(REV: i 9 51 �j4 <br /> EH 14-28 <br />