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APPLICATION FOR PERMIT F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA D <br /> -Telephone (209) 466-6781 F <br /> PERMIT EXPIRES 1 YEARFROMDATE 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 scribed. 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 i <br /> Local Health District. O A I3 <br /> Job Address 3�7'` �ij �+t 1n� M1 7 � i City D� Lot Size 1C PM <br /> Owner's Name o/-1 �'l" �- i'1 aft a Address _f-� ,OC3 Al s ��1� Phone <br /> Contractor Address License No. Phone <br /> I <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. I::1I;I9I­7MT <br /> FOUNDATION AGRICULTURE WELLL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA G CTION SPECIFICATIONS.. <br /> ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing' Specifications <br /> Ll Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P, State Work Done <br /> Well Destruc' 1 ❑ Well Diameter "" Sealing Material (top 601 <br /> Depth f Filter Material (below 501 <br /> TWE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No-septic system permitted if public sewer is <br /> available within 200 feet.) t <br /> Installation will serve: Residence_ Commercial— Other"" 4 <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. ❑ F Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linesV Total length/size + <br /> FILTER BED ❑ Distance to nearest: Weil Foundation - 'Property Line <br /> SEEPAGE PITS n Depth Size ! Number <br /> SUMPS ❑ Distance to nearest:. Well -'Foundation '-Property Line <br /> DISPOSAL PONDS ❑ I <br /> II 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 j <br /> (rules and regulations of the San Joaquin Local Health District. 4" <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 /> Lhapplican st cal or all required i ctio s Complete drawing on reverse side.d Title: `^ ��� Date: �� <br /> OR DEPARTMENT USE ONLY <br /> A� � �Q, V ` <br /> ;Application Accepted by r a 'Y1lL -� � Date ►�4-. L+ Area �p <br /> Pit or Grout Inspection by Date Final Inspection by _ Date "`o <br /> Additional Comments: <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 RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 14-2411iEV.t/rill t,�� UC S rD r�y / if) <br /> EH 14-2a a �% /7 � <br />