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APPLICATION FOR PERMIT <br /> " SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ; <br /> Telephone (209) 456-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4 <br /> F: (Complete in Triplicate) <br /> Application is hereby madeto the San Joaquin:Lpca1 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 /> &1&4Job Address City 6t Size PM I <br /> Owner's Name Address ` r Phone <br /> Contractor <br /> -License No. -9si? - Phone�I <br /> TYPE OF WELL/PUMP: NEW WEt11• WELL REPLACEMENT ❑ DESTRUCTION ❑ j <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L NES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICUL URE ELL OTHER WELL PITS/SUMPS <br /> i <br /> k INTENDED USE TYPE OF WELL PROBL4AREANSTRUCTION SPECIFICATIONS <br /> { , <br /> ❑ Industrial ❑ Open Bottom ❑ Mana. of Well Excavation Dia.-of Well Casing <br /> C❑ Domestic/Private LJ Gravel Pack �,0 Tracpe of Casing Specifications <br /> '('1 Public n Other Cl Deltpth of Grout Seal Type of Grout _ <br /> I I Irrigation --Approx.-Depth i I Eastrface Seal installed byRepair Work Dane ❑ Type of Pump State Work Done <br /> Well-Destruction ❑ Well Diameter Sealin Material (top 50') c; <br /> Depth t filler Material (Below 50') y. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION It—REPAIR/ADDITION L 1 DESTRUCTION 11 INo septic system permitted if public sewer is <br /> " available within 200 feet.) <br /> Installation will serve: Residence r Commercial_ Other <br /> Number of_li_vi_ngrunits:,-fes Number of bedrooms _ r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg b Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ / Method of D^isp I <br /> Distance to nearest: Well [Q Q Foundation 5' Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> ""qq G sz <br /> FILTER BED ❑ Distance to nearest: -Well 1t— oundation �" _ Property Line <br /> SEEPAGE PITS I i Depth" Size '' ( v. <br /> Number,.- <br /> SUMPS :L-J Distance to ne est-- WeII/ (? Foundation�; -"Property Line <br /> DISPOSAL PONDS ' ❑ w�~"`� " " "'�! l <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 Di§trict. <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 Maws 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." v t <br /> The applicant ust call for required 1 pections. Complete drawing on reverse.side. <br /> Signed X 1Titla Date: <br /> 0.0' F DEPARiMENT.USE ONLY <br /> Application Accepted by Date �n Area ` L <br /> �- ' <br /> Pi o Grout Inspection by I–�-- , Date d Final Inspection by�tJI�1/l Date <br /> _c <br /> ditional Comments: U d"S !k –�jD <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 /> 1 ' <br /> CK <br /> I iFEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +,EH 1321(REV.+/n e1m- .O V„1 /o( <br /> .. <br /> EH 11-26 V V <br />