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5 <br /> APPLICATION FOR PERMIT <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 /> (Complete in Triplicate) <br /> I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workhrerein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weN/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> k Job Address <br /> t City Lot Size !�j <br /> ��lL� PM <br /> V.wo—Owner's Name , <br /> s Address <br /> Contractor. Phone <br /> - <br /> i <br /> Address, <br /> "i ,• }. <br /> ITYPE OF EL PUMP: Liic�- cense Phone <br /> NEW WACE <br /> ELL ❑ WELL REPLMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> DISTANCE TO NEAREST:`SEPTfC TANK SYSTEM REPAIR EJ OTHER LJ { <br /> ' ``SEWER LINES DISPOSAL FLD.' <br /> FOUNDATION t``AGRICULT E PROP. LINE <br /> WELL"� <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROB AREA CONSTRUCTION SPECIFIC <br /> ❑ Open BottomATIONS <br /> ❑ Industrial ❑ Maniac <br /> �' Dia. of Well Excavation <br /> LlDomestic/Private ❑ Grayer"Pack Dia. of Well Casing <br /> t bf'1 Public' ;r ❑ Tract Type of'Casing " , <br /> ❑ Other t, '4 Specifications <br /> { { .w F1 Delta[ Depth of Grout Seal <br /> I ! Irrigationi Type of Grout <br /> 0 —_Approx. Depth I I Eastern a <br /> Re�Seal7nstailed b <br /> Repair Work Done C7. Type of Pump H ^-_;'# Y 'l <br /> Well DestructionCl: ;', State Work.Done <br /> Well Diameter ealing Material (top 50') <br /> Depth <br /> _ Filler Material !Below 5011 <br /> TYPE OF:SEPTIC WORK: NEW fNSTALLATION I,I REPAIR/ADDITION I 1 OESTAUCTiO I (No septic system permitted if public sewer is <br /> U� <br /> Installation will serve: Residence i Commercial vailable withinin 200 <br /> Other _ <br /> Number of living units:�� Number of bedrooms <br /> Character of soil to a depth!of 3 feet:.." <br /> SEPTIC TANK ❑ Type/Mfg x --cWater table depth <br /> ity • _ M <br /> . ,PKG. TREATMENT PLT. ❑ No. Compartments <br /> �� �� CapaMethod of Disposal <br /> Distance to.nearest: Well Foundation <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> . . <br /> FILTER BED Total length/size <br /> ❑ Distance tornearest:. Well Foundation <br /> s Property Line <br /> ]SEEPAGE PITS 11 Depth <br /> SUMPS Size Number t <br /> CI�Distance .nearest: <br /> ❑ _ Well __Foundation _ Property Line j ! <br /> DISPOSAL PONDS - � _ ,_ �_-� <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: and <br /> formance <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's for thiring'oresub-contracting s gnatnot <br /> urre <br /> certifies the following: "I certifythat in the 'Performance of the work for which this permit is issued, I shalt employ tion laws of California." A <br /> 0 Y persons subject to workman's compensa- <br /> The.applicant tali for a requir d inspections. Complete drawing on reverse i�.4 <br /> Signed X .t <br /> Title: <br /> . . Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by " r y <br /> A Date ��] > <br /> Pit or Grout inspection by t. <br /> Area <br /> Date Final inspection by <br /> Additional CommenDate ;? <br /> ❑ Stk 466-6781 *,. <br /> f ❑ Lodi 369-3621, I] Manteca 823-7104 0 Tracy 835-6385 1 <br /> Applicant - Return all copies to: Environmantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE INFO AMOUNT REMITTED CASH RECEIVED BY DATE <br /> ,est PERMIT'NO. <br /> + EH 14-26 IREV..i i rt 57 -� -[ a, _ <br />