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as <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �l'// <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 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 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 � �� Ci Lot Size. PM <br /> Owner's Name ✓�'G Address �i P _- Pho� <br /> f d3 <br /> Contract Address icense Phq►� <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. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS S3JW <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC! <br /> ❑ Industrial ❑ Open SottorYi - ❑ Manteca Dia. of Wavaiion Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications <br /> ❑ Public F1 Other 171Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. D [ I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Typ ump H.P. State Work Done <br /> Well Destruction ell Diameter Sealing Material atop 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION No septic system permitted if public sewer is <br /> available within 200 reef.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Weil Foundation Property Line <br /> LEACHING LINE. ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:` Well _ Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ r'. Number <br /> SUMPS ❑ Distance to nearest: Well Fqundatian 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 Di§trict: <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 /> The applicant all required inspections. Complete drawing on rev rse side. {} `t <br /> Sign Title: Date: / \\ — <br /> FOR DEPARTMENT USEONLY <br /> Application Accepted by Date �� ��"'� Area <br /> Pit or Grout Inspection by Date Final In by Date Q <br /> Additional Comments: C �r <br /> 11 <br /> ❑ Stk 466-8781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK 11 <br /> CASH RECEIVED BY DATE PERMIT"NO. <br /> +.EH14-24fREV.iinSl 7�,�_ ��� <br /> EH 14-26 ~• 1 <br />