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w <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT L <br /> 1601 E. HAZE T ON AVE.; STOCKTON, CA <br /> f Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) " <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constiuct 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 0 ` Ci Lot Size PM <br /> Owner's Nam <br /> i —dress 021 _ ,�,� Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION.El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TON ST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> UNDATION AGRICULTURE WELL QTH£�L PITS/SUMPS <br /> INTENDED USE >D0 <br /> LL PROBLEM AREA CONST N SPECIFICATIONS ' <br /> ❑ Industrial ❑ ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ;r ❑ Domestic/Private ❑ acy Type of Casing Specifications <br /> ❑ Public ❑ to Depth of Grout Seal T Type of Grout <br /> C1 Irrigation ❑ Eastern Surface Seal Installed byRepair Work Done ❑ TyH.P. State Work Done <br /> Well Destruction ❑ WSealQ Material (top 501 <br /> Depth Filler r4laterial (Below 501 {� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DEST—RUCTfONX No septic system permitted if public sewer is v <br /> available within 200 feet.i l <br /> Installation will serve: Residence Commercial— Other i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:I Water table depth <br /> SEPTIC TANK ❑ Type/Mf � 1 <br /> 9 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal i <br /> Distance to nearest: Well .y Foundation a Property Line .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 'l -S ize Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line S : <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 t <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, l shall not 1 <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." ! <br /> The applicant must call for all required irispec ons. Complete drawing on reverse side. <br /> SignedTitle: Date: <br /> r � . <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted y `� Date y Area <br /> fA <br /> .._.w ....- <br /> Pit or Grout Inspection by Date Final Inspection by �` Date -� D <br /> B <br /> Additional Comments: ilA'�ko Oil bo-IL 01 A(r- S" <br /> ❑ Stk 466-6761 ❑ Lodi . 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFOLgOUNT DUE I�: AMOUNT REMITTED CASH RECEIVED BY DATE PER MIT'NO. <br /> + EH 3-24 EH 14-24(REV.1/85) <br /> J <br />