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7` <br />! <br /> f APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . ; <br /> Pr n 3 <br /> (Complete in Triplicate) ' <br /> tv�P CES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d Aicat on is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an ,�fltTie San Joaquin <br /> Local Health District. / �� <br /> Job Address 3 57a IfL 10 i City " Lot Size PM <br /> Owner's Name .f 7- Address Qrr y J _ Phone "•'�� r <br /> Contractor Address S' ! _License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL)k. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Y REPAIR ❑ fOTHIEp ❑ �r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW LINES DISPOSAL FLD.6a PROP. LINE dC� <br /> FOUNDATION AGRI LTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR LEM AR CONSTRUCTI4+ SPECIFICATl S rj <br /> ❑ Industrial ❑ Ope . omMa teca Dia. of Well £x vati Dia. of Well Casing 16 <br /> Domestic/Private XGra Pack ❑ Trac Type of Casing Specifications <br /> ` <br /> ❑ Public IDOt er ❑ Delta �epth of Gro <br /> ❑ Irrigation pprox. Dep ❑ Eastern Nace Seal Inst lied by Q W ype of Grout ' it <br /> Repair Nrk Done Type f Pump H. State Work Done <br /> Well De str tion Well iameter Sea` ng Materi (top 50' <br /> Depth Filler aterial (B <br /> TYPE OF SEP C W K: NEW? STALLA ON ❑ REPAIR/A ITION ❑ DESTRUCTION CJ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installatio ' ary NEW <br /> ommercial_ Other <br /> Number of livin ni Number of bedrooms <br /> Character of soil t a depth of 3 feet: Water table depth ` <br /> SEPTIC TANK ❑ Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT PL . ❑ Method of Disposal <br /> Distance to nearest: Well Foundat Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengt <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ — '— --� <br /> 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. i <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 m for al req 're inspections. Complete drawing on revs se side. ; <br /> Signed Title: Date: <br /> F R DEPARTMENT USE ONLY /! <br /> Application Accepted by Dafe' ��" 7 Area �US <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 0 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 zff 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 /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24 IREV. /B 57j <br /> EH 1426 <br />