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E5 f <br /> 5 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �f <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 1 <br /> - k <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) + wa r 3 r'J h. I <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. I <br /> of Size <br /> [�Y7FTE <br /> b Address � � � � city � <br /> PM <br /> �C-4lif- d /� Phone <br /> ners Name f ddress . <br /> r <br /> ntractor _:_ -Address �' License No. Phone <br /> OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j <br /> PUMP INSTALLA ON ❑ S M REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRIC1;Z RE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PRDBL EA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Ma ca 7Dia. of Well Excavation , Dia.of Well Casing <br /> ❑ Domestic/Private- --P Gravel Pack- -r racy- --�-- ypof Casing - Specifications <br /> FI Public F� Other Delta th of Grout Seal Type of Grout <br /> I I Irrigation —.-Approx. Dept t I I Eastern l Surfa eal Installed by - <br /> Repair Work Done ❑ Type of Pump T.., HLP: f i * State Work Done_ <br /> Well Destruction ElWell Diameter Sealing Material Itop 50') <br /> Depth Filler Material,(Below 50'1 _ T <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION t I DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200.feet.I <br /> r , <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms f <br /> 4 Character of soil to a depth of 3 feet: '� r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity-L­ No. Compartments <br /> PKG. TREATMENT PLT. ❑ r s o Method of Disposal <br /> Distance to nearest: Well 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 I I Depth Size Number <br /> SUMPS L) Distance to nearest: Well Foundation 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 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."Contractor's hiring or sub-contracting signature <br /> certifies the following: " 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 Califor <br /> The applicant mu all for atl mquir i ctions. Complete drawing on reverse side. -7 <br /> Signed X r Title: �tl^i/ Date:[ <br /> ► FOR DEPARTMENT USE ONLY <br /> c <br /> Application Accepted by Date �� Area <br /> Pit or Grout Inspection y Date Final InspQFtion by Date <br /> Additional Comments: I <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385— <br /> Applicant <br /> 35- 5Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelto Ave., P.O. Box 2009, Stk., CA 85201 <br /> FEE AMOUNT DUE UNT REMITTED ASH RECEIVED BY DATE PERMIT'No. <br /> INFO <br /> I„tel! ffivr & In :e <br /> f* �f " /" <br /> +•EH13-241REV.r/n5) r""� <br /> EH 14-28 <br />