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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,.,STOCKTON, CA <br /> Telephone 091 466-67$1 <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 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 /> Job Address , y City v�. Lot Size ASS ���_ PM <br /> Owner's Name-�, " Address _413 �� one <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL ELI PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO TION SPECIFICATIONS <br /> ¢ r <br /> CJ Industrial ❑ Open Bottom ❑'Maritec Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> Ih ❑ Public ❑ thr ❑ pelta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �._..-fPpPr.0, <br /> x. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Do p H.P. { State Work Done <br /> E <br /> Well D uction ❑ Well Diameter Sealing Material-ltop 50'1 b P <br /> Depth _ <br /> .. .Filler„ {B <br /> Material_ elow 50'1 <br /> if ,,. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION`❑ REPAIR/ADDITION f❑ DESTRUCTION (No septic system permitted if public sewer is 11 <br /> Ik available within 200 feet.! �l <br /> Installation will serve: Residence Commercial Other , <br /> Number of riving units:r Number of bedrooms <br /> Character of soil to a depth of 3 feet: I <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg `' Capacity No. Compartments <br /> PKG. TREATMENT PLT- ❑ r Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> LEACHING LINE ❑' No. & Length of 14's- Total length/size <br /> FILTER BED ❑I -Distance to nearest:- -Well Foundation Property Line <br /> ' j s <br /> SEEPAGE PITS ❑ Depth Y —.-f- 1-1-Size Number <br /> SUMPS ❑ Distance to nearest: Well _:Foundation- -- Property Line- I <br /> ZDISPOSAL'PONDS ;-r❑ <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 Joaquiri Local Healih District tr <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 /> i i <br /> em <br /> p oy any person in such manner as to become subject to workman's.compensationIaws of�California:”Contractors 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 <br /> employ Persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mst call for all' rei9'inspections. Complete drawing on reverse side. <br /> u �G�Signad Title: Date: 4 <br /> FOR DEPARTMENT USE ONLY (� �,�� <br /> Application Accepted by Date i Area <br /> Pit or Grout Inspection <br /> /b Date Final Inspection by Date <br /> Additional Comments:/ <br /> ❑ 5tk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> ii Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK "RECEIVED 8Y' DATE PERMIT NO. <br /> +'EH 14-24IRE <br /> V.1/957 <br /> EH <br /> -28 <br /> i <br />