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• '"' APPLICATION FOR PERMIT <br /> �S <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 : -, • i <br /> {Complete in.Triplicate} <br /> Application <br /> 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 _,Z _�— a le`��� ---'.City j' Qc;( of Size <<� �' PM <br /> Owner's Name ZM! .�/C� �v4HAr�sd Phone <br /> t <br /> Contractor � � ,;� Address License No. Phone <br /> TYPE OF WELL/PUMP: W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑. <br /> PUMP INSTAL ION ❑ SYSTEM REPAIR ❑ OTHER ❑ . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PR -LINE <br /> FOUNDATION AGRICULTURE WELL OTH PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CON'S N SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of.Well Casing <br /> Ll Domestic/Private ❑ Gravel Pack E] T Type o, sing Specifications <br /> ❑ Public ❑ Other- Ll Delta Depth of Gr -Seal Type of Grout <br /> LJIrrigation I x Depth ❑ Eastern Surface Seal Inst ed by - <br /> i <br /> Repair Work Done ype of Pump H.P. tate Work Done <br /> 4.. Well Destructio ❑ Well Diameter `Sealing Material (top 50') 1 <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 within 200 feet.) t(1� <br /> In will serve: Residence Commercial_ Other - <br /> Number of living units: Number of bedrooms <br /> .1 <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 /> t Distance� !to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distanceito nearest: Well Foundation Property Line <br /> 5 't <br /> SEEPAGE PITS ❑ Depth Size Number ' <br /> SUMPS ❑ Distancelto nearest: WellFoundation - Property Line <br /> DISPOSAL PONDS ❑ r <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 /> 1 rules and regulations of the San Joaquin Local Health District. '" <br /> tttl 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 /> r 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 /> 6 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." <br /> i � <br /> The icant must call for all required inspections. Complete drawing on reverse side. <br /> r. - <br /> J <br /> Signed Title: Date: <br /> FOR DEPARTMENT DISE ONLY f n <br /> f ' r _ fJ7� <br /> F Application Accepted by ' Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date J <br /> 1 Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369,-3621 t ❑ anteca 823-7104 o- ❑ Tracy 835-6385 <br /> L Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,-P.O. Box 2009; Stk., CA 95201 <br /> FEE AMOUNT DUE `AMOUNT REMITTED A # RECEIVEp BY DATE' PERMIT' <br /> INFO /rp- <br /> + EH 13-24[REV.iinsl �V* #�S O� ,rte YT --'• _ "�'--^^'f ..,,.,w }�-4 1`/ <br /> EH 1428 <br /> �l.v `7—Y <br />