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APPLICATION FOR PERMIT -"- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT / <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA if <br /> l Telephone (209) eT8T""^ <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 /> -'7� <br /> Job Address , / �I<V141 City r c:: f Lot Size PM <br /> Owner's Name �f Address /F` 1 ' Phone <br /> t <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCT I N ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ .. OT R ❑ <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/ JUMPS. <br /> INTENDED USE 'TYPE'OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of all Casing <br /> ❑ Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing Specific ions oe <br /> E f`1 Public ❑ Other Cl Delta Depth of Grout Seal Type of rout ._ <br /> t I Irrigation _..Approx. Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') 1N <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i (No septic Sysermi ted if public sewer is <br /> available withii tet <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 t le"h <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Co pa _nt <br /> PKG. TREATMENT PLT.❑ Method f os <br /> Distance to nearest: Well Foundation Property Line VVVVVV <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 11 <br /> FILTER BED ❑ Distance to nearest: Welt _ Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS L1 Dista <br /> DISPOSAL PONDS El <br /> I hereby certify that t have prepared this application and that the JorFWM be doe in AccorganLe w h San Joaqu i county rdinances, state laws, and <br /> rules and regulations of the San Joaquin I ealthD twin,. <br /> Home owner or licensed agent's signature les e o owing: cern y t at m the pe ormance 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.must call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> g Title: _ Date { >f <br /> �- FOR DEPARTMENT USE ONLY <br /> r Application Accepted by dn.11.�'�>. Date �f " ;' Area <br /> Pit or Grout Inspection by Date Final Inspection by } Date <br /> Additional Comments: <br /> ❑ Stk 466.6781 . ❑ 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 CASH RECEIVED BY DATE PER IT'NO. <br /> ♦.EH 13.21 EREV.1 H 5) ,F .'r/ ,/y .� / f f Y ' <br /> EH 11-26 �,.- <br />