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n In <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCIKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 sewag or No. 1862_for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 273 2 <br /> Job Address City Lot Size PM <br /> y Owner's Name �r+'l l�1 if� t dP:�f� <br /> Phone 6l �ContractordressILicense No.� � ' Pho �� �`1_.] <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> -- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES POSAL FLD. PROP. LINE <br /> Fa FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> �= INTENDED USE TYPE OF W LL LEMAREA CONS-Y CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private.. ❑ Gravel Pack ❑.Tracy Ty ing Specifications <br /> ❑ Public ❑ Other ❑ Del Depth of Grout a Type of Grout <br /> ❑ Irrigation �4pprox. Depth Eastern Surface Seal Installed by <br /> Repair Work Done; ❑ , Type of Pump H.P. State Work Dane <br /> Well Destruction ❑ Well Di eter Sealing Material (top 50') <br /> `Y Depth Filler Material.(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑.IN septic system permi public sewer is <br /> - a1 withi 200 flee <br /> { Installation will serve: Residence Commercial_•Other ' <br /> Number of living units: � Number of bedroom <br /> Character of soil to a depth of 3 feet: �rr� W er table depth <br /> SEPTIC TANK ❑ Type/MfgCapacity .No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of.Dissppos <br /> Distance to nearest: Weil/b d Foundation ^� property Line <br /> I <br /> LEACHING LINE �No. & Length of lines c Tota! length/size <br /> FILTER BED ❑ Distance to nearest:: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth SiieNu bar <br /> SUMPS �' Distance to nearest: Well f oundation Property Line <br /> i DISPOSAL PONDS ❑ <br /> I I hereby certify that I have prepared,thiq application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 'J rules and:regulations:.of the San Joaquin Local Health District..,., <br /> ..Horde owner or licensed agent's signature icertifies'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 applican%mus all for all required"inspectioris. Complete drawingon reverse side. i <br /> Signed X A I t - Title :> f Date: j . <br /> 4 FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date "` Area I <br /> Pit or Grout Inspectio y Date Final Inspection by Date <br /> ­ <br /> t <br /> Additional Comments: i!PJ'a v i1- 'p 1r, t <br /> ❑ 5tk 466-678'1 ❑ Lodi369-3621 ❑ Manteca -1104 ❑ 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24MEv.1/a5i --7� <br /> EH 14-26 C 3 s -75Z <br />