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Ih APPLICATION FOR PERMITES5 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> `.� 1601 E. HAZELTON AVE., STOCKTON CA 13'a'lq <br /> I� Telephone (209) 466-6781 I <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 <br /> ss City Lot Size.X Zia PM <br /> - Owner's Name �dddress <br /> Phone <br /> Contractor li <br /> Address License No. ' <br /> TYPE OF WELL/PUMP: --- Phone <br /> KNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl <br /> �2� EAREST; SEPTIC TANK OTHER <br /> — SEWER LINES DISPOSAL FLD. +PROP. LINE <br /> OUNDATION AGRICULTURE WELL w i <br /> INTENDED USE TYPE 0 .: ¢OTHER W ) PITS/SUMPS, <br /> PROBLEM AREA CONSTRUCTIONS CATIONS <br /> ❑ Industrial --- <br /> w ❑ Open Bottom ca Dia. of W cavation <br /> ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> ❑ Trac <br /> I` Y f Casing Specifications <br /> ❑ Public ❑ Other !I ❑ Delta Depth of Gro I <br /> ❑ Irdiatio_n Type of Grout v, <br /> _�4pprox.'Depth stem Surface Seal installed�by <br /> Repair,Work Done _❑ Type of Pu H P <br /> Well Destruction ❑ Work Do <br /> iameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC EPA <br /> WORK: NEW INSTALLATION O RIR/ADDITION ❑ DESTRUCTION N (No septic system permitted if public sewer is <br /> Installation will serve: Residence II Commercial available within 200 feet.) <br /> _ Other T <br /> Number of living units: Number of bedrooms 4 <br /> a � <br /> Character of soil to a depth of 3 feet i <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ II <br /> � Method of Disposal <br /> Distance to nearest: Wel Foundation <br /> Property Line <br /> LEACHING LINE ❑ No. 8, Length of fines <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest: Weli Foundation property Line <br /> SEEPAGE PITS ❑ Depth IM - Size- Number <br /> SUMPS <br /> ❑ Distance too nearest: Wel Foundation <br /> DISPOSAL PONDS ❑ 'i Property Line <br /> i_ <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 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."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 employ persons subject to workman's compensa- <br /> tion laws of California." Ik <br /> The applicant ust tail for all required in ctions. Co plate drawing on reverse side. <br /> Signed Title: <br /> Date: cam! <br /> FOR DEPARTMENT USE ONLY i <br /> Application Accepted b t� <br /> ' I Date oF- `��' Area <br /> Pit or Grout Inspection �! Date Final In ' <br /> i spection by Date ?� <br /> Additional Comments: li + <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy -835-6385 <br />_y Applicant_ Return all copies to: Environ ental Health Permit/Services.,601..E. Hazelton Ave., P.O. Box 2009,-Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> CASH RECEIVEE151YE DATE PERMIT'NO. <br /> + EH 13-24{REV.7/es) i` 3� v� 'y'EH W29 -3 L '� <br /> Il' <br />