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APPLICATION FOR PERMIT <br /> 1k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <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 /> f <br /> Job Address —/ t7 + L/ t ' /1 9 City Lot Size <zu..PM <br /> Owner's Name Address ' Phone 9S <br /> Contractor Ldde,s .. license No. vTPhone L '� <br /> TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> - PUMP INSTALLATION ❑ SY M REPAIR p OTHER El <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK S ER LINE DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGR ULT E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE I TYPE OF WELL PROBLAARCONSTRUCTION SPECIFICATIONS❑ Industrial ❑ Open Bottom ❑ ManWell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracf Casing Specifications <br /> n Public ❑ Other CI Deltaof Grout Seal Type of GroutI Irrigation _-Approx. Depth I I EastSea4-Installed byRepair Work Done 0 Type of Pump —~ . . l .,State Work Done_ <br /> Well Destruction ❑ Well Diameter + Sealing Material (to.1 1p 50'l.'' t -- (� <br /> Depth Filler Material (Below 50'I " '��° L� <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION K REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence i�Y Commeicial Other t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet- Water table depth I <br /> r J <br /> r SEPTIC TANK ❑ Type/Mfg. Capacity 0 0 No, Compartments <br /> PKG. TREATMENT PLT. ❑ ` y F Method of Disposal <br /> Distance to nearest: 'Well Foundation� Property.Line , 0 t7 p' <br /> LEACHING LINE ❑ No. & Length of lines 3 Total length/s Z,-1,5q� <br /> FILTER BED ❑ Distance to nearest: Well /[ t7 Foundation .3 J2 -_ Property Line <br /> f'e'e: - <br /> SEEPAGE PITS I I Depth zSize Number <br /> f SUMPS ❑ Distance to nearest: Well Foundation 9 a Property Line 7,5:� <br /> DISPOSAL PONDS ❑ t t �- r I P <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 Y <br /> ' -rules and regulations of the San Joaquin Local Health Dt%trict. <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 a <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 t <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- 1. -. <br /> tion laws of California." 17 <br /> Th applicant st call for all required inspections. Complete drawing on reverse side. <br /> f Si ned X Title: LT ,rA"kl_A.,L/ Bate: <br /> DEPARTMENT USE ONLY � �� '� t <br /> D Application Accepted by QLin 461' —'� '��. S�a••.%•Q•_� Date ���b�� l Are . <br /> b Pit or Grout Inspection by Date Final Inspection by Date— r <br /> Additional Comments: "_ t <br /> i ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> FEEE <br /> CK 11 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. <br /> •ter ^� � / (//.//1 <br /> r +.EH13-291REV,tin5Y <br /> EH 1428 VV <br />