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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 5 Telephone 12091 466-6781 <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 construct and/or install the work hereiri 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. - I <br /> r r <br /> Job Address r� 'A' City Wei Lot Size PM <br /> 1 <br /> Owner's Name -;�u�.l��nl `"' Address Phone <br /> Contractor�.4�C `- pr-_Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION {] SYSTEM REPAIR D OTHER ❑ �— <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD ROP.�LINEFOUNDATION AGRICULTURE WELL OT LL PITS/ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU. SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca . a Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> * Public I_l Other 1 ❑ Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation _..Approx;; Depth l l Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump.' H P'^-""�^"�^"�`" y ''State Work Done <br /> Well Destruction ❑ I Well Diameter Sealing Material (top 501 _I <br /> r Depth i-)Filler Material (Below 501 t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REP AIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> k " available within 200 feet.) \ <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/Mfg Capacity t No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well f Foundation t Property Line <br /> LEACHING LINE ❑ No. & Length of lines ggTotal length/size <br /> FILTER BED ❑ Distancetto'oearest: i Well } Foundation x Property line <br /> SEEPAGE PITS I I Depth r Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> DISPOSAL, PONDS Cl I 9 <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 taws 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 ii issued;I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st call for all requir inspe tions. tromplete drawing'.on reverse jde <br /> Signed X �'� Title: _ - &-`74. t 1-42-7 Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by t _ Date Area <br /> Pit or Grout Inspection by� { Date Final Inspection by 140F Date&Z2--1fr19- <br /> Additional Comments: Nehlmll <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CKSH RECEIVED BY DATE PERMIT-NO. <br /> +.EH 13-24(REV.t/x5) <br /> EH 14-28 <br />