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' APPLICATION FOR PERMIT <br /> ., SAN JOAO.UIN,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> - PERMIT EXPIRES 'I 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 /> 4 Job Address _/Q FCity, i Lot Size PM <br /> £� <br /> W Owner's Name •`� Address Phone <br /> F. Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> l <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ HER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE <br /> k FOUNDATION i AGRICULTURE OTHER WELL PITS/SUMPS <br /> . INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavafion.- Dia. of Well Casing <br /> ❑ Domestic/Private <br /> ED Gravel ❑ Tracy Typeof Casing Specifications <br /> ❑ Public ❑ 17 Delta De th of Grout S I 'P ea T e� Type of Grout <br /> ❑ Irrigation <br /> d <br /> g �[nl <br /> ---Approx. Depth t ❑ Eastern Surface Seal In ... <br /> stalled by <br /> Repair oype'of Pump H.P. State Work Done <br /> ell Destruction ❑ Well Diameter. Sealing Material ltop 50'1 <br /> Depth Filler Material {Below 50'1y f <br /> TYPE OF'SEPTIC WORK: NEW INSTALLATION ❑' REPAfR/ADDITION ❑ DESTRUCTIO INc se"ptic system permitted if public sewer is <br /> available within 200 feet.) <br /> i Installation will serve: Residence i Commercial_ Other <br /> Number of living units` ,rNumber•of bedrooms n <br /> Character of soil to a depth of 3 f et:t. I' A—A Water table depth- <br /> SEPTIC <br /> ept 1 ' <br /> SEPTIC TANK Type/Mfg` — - opacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ k Method of Disposal <br /> 4 + <br /> Distance to nearest: '4i Well Foundation Property Line � <br /> LEACHING LINE ❑ No. & Length of lines ' Total length/size <br /> FILTER BED ❑ Distance to nearest:. Well Foundation 'Props Line <br /> �(Nwmbe <br /> SEEPAGE PITS Depth Sizer a <br /> SUMPS ❑` Distance toln�;earcit-7' <br /> , Well . Foundation -Property Line <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 <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 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 /> Thea icant t all f r,all require insp,etions. Complete drawing on reverse side. <br /> Signed Title: _ Date: <br /> 1 '�'/ L <br /> FOR DEPARTMENT USE ONLY � � x <br /> Application Accepted by r Y` Date Area <br /> Pit or Grout Inspection b [[ Date Final Inspection by -4 Date <br />` Additional Comments: <br /> l ❑ Stk 466-6-, Lodi 369 3621 ❑ Ma to 823-7104 ❑ Tracy 835- <br /> Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ly <br /> k <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. , <br /> EH [ �J <br /> + EH 14-261REV.iiH51 �� �� �� !� G/� `1 <br />