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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA t <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 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 /> Ail <br /> 1� p0 Lw. <br /> Job Address � City Lot Size X/� y PM <br /> —F # 5 1V -SAME <br /> A - <br /> ._ Phone <br /> Contractor <br /> ddress d Ott il 441. \ <br /> License No.�6�-(���Phone � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ <br /> WELL REPLACEMENT 04 DESTRUCTION ❑ <br /> 4. <br /> PUMP INSTALLATION ❑ SYSTEM_:REPAIA.C. __ „0KOT.HER%❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES POSAL FLO. PROP. LINE <br /> raw. <br /> FOUNDATION AGRICULTU <» - OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBL EA CONSTRUCTION FSPECIFICATIONS (I ' <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation +i ?_ Dia. of Well�Casl <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Casing ; Specifications <br /> ❑ Public ❑ Other ❑ Delta D41h.of Grout Seat <br /> P•,�� ' Type of Grout l' <br /> ❑ Irrigation �pprox. Depth ❑ Eastern Sur.ac_e Seal Installed by 1 t. <br /> Repair Work Done ❑ T p ` •�++nwr.�ws ` <br /> Ra Type of Pum H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR%ADDITION DESTRUCTION (No septic system permitted if public sewer is <br /> ailable within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> - "' <br /> Number of living units: Number of bedrooms z' 10 <br /> Character of soil to a depth of 3 feet:I I J <br /> SEPTIC TANK Type/Mf I ` a Water able depth YY <br /> 9 _ Capacity No. Compartments S <br /> PKG. TREATMENT PLT. ❑ !� 1If` V�Methodrof Disposal <br /> Distance to nearest: Wel) Foundation Property Line ! <br /> NLEACHING LINE ❑ No_ & Length of linesgt <br /> Total len h/size <br /> FILTER BED ❑ Distance to Foundation Property Line <br /> nearest: Well r t <br /> SEEPAGE PITS Depth Size <br /> - Number <br /> SUMPS. El' Distance to nearest: I•:Well Foundation Property Line r <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the w ork will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin.Local Ha District.1. <br /> Home owner or licensed agent's signature certifies the following: �l certify that in the performance of the work for which this perrriit issued I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of CalifomI Contractor's hiring.or.suO contracting signature <br /> certifies the following:"I certify that in the performance of the work for Which this permit is <br /> tion !shall employ persons subject to workman's:compensa <br /> tion laws of California." <br /> Thea applicant m call for all re uired insf � i+ A E <br /> i h <br /> pp q pections. Complete drawing on reverse side' P,�,.w <br /> f� c! <br /> Signed ""`y'" """ '�-Titib-o." t f LIS q <br /> l FOR DEPARTMENT USE ONLY Q { <br /> + — L- Ro <br /> Application Accepted by Data Area f ! <br /> Pit or Grout Inspection by Date Final Inspection by ' Date <br /> Additional Comments: /q 3 <br /> ❑ Stk 466 781 ❑ Lodi 369-3621 ❑ Manteca BM-7104 ❑ Tracy 5-6385 <br /> Applicant- Retum all copies to: Environryienta! Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> j + <br /> - FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH;8-241REV.5iR57EM 4-25 <br /> j h y ..Ha -a _. . _ <br />