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0 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.;,STOCKTON, CA <br /> 'Telephone 009)'466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> (Complete in Triplicate) 1 <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 / u'i - <br /> �" Ci Lot Size PM <br /> - Owner's Name R Address _v <br /> Phone <br /> Contractor "E7r sr--L 1 <br /> Address LicenseWo� Phone <br /> TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT ❑ tiSTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOS PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL 1'—PROBLEM CONSTRUCTION SPE61I(CATIONS <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Weil Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pa p Tray Type of Casing �— <br /> Specifications <br /> L1 Public ❑ r ❑ Delta v� Depth of Grout Seal <br /> Irrigation �q f'EaType of Grout <br /> 17 Irrigation Depth❑ stern Surface Seal Installed by <br /> Repair Work e El Type of Pump H.P. 1 <br /> State Work Done <br /> Well ruction ❑ Well Diameter Sealing Material (top 50'1 i <br /> Depth s Filler Material (Below 50') I . <br /> TYPE-OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence!v Commercial Other I <br /> � - f , <br /> Number of living units: Numbew�oTbedrooms ffff <br /> Character of soil to a depth of 3 feet: c? <br /> Water table depth <br /> SEPTIC TANK ElType/Mfg + Y NCa acit " <br /> PKG. TREATMENT PLT. Eli p o. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation PropertyLine j <br /> 8 <br /> LEACHING LINE ❑ No.'& Length of lines; Total length/size <br /> FILTER BED �'"' <br /> ❑ Distance to nearest: ,. WellFoundation-- Property Line <br /> SEEPAGE PITS ❑ Depth - ' Size <br /> Number <br /> SUMPS ❑ Distance to nearest: 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." + f <br /> ficant must call for all req d inspectio✓ns. Complete drawing on reverse side. <br /> Signed' <br /> T; <br /> 9 Date: <br /> .FOR DEPARTMENT USE ONLY <br /> Application Accepted by DateQ <br /> Area p <br /> Pit or Grout Inspection by Date Final Inspection by--201'u(� <br /> _ Date <br /> Additional Comments: �.c�� ,, <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED # <br /> INFO SH RECEIVED BY DATE PERMIT�NO. <br /> a EH13-24(REV.I/H s) - — <br />