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{ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> { Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to co i1rucfd/.ol":install he o herein described.This application is <br /> made in compliance with.5a,�n Joaquin County Ordinance No.549 for sewage or No. 1 � 41 patElLocal Health District. --%and the jes and Regulations of the San Joaquin <br /> Job Address _ .� _ ti kII '� �l�-2_L�` <br /> City t Size. <br /> '""` PM <br /> Owner's Narrie .� <br /> I �« Address <br /> Phone 2— <br /> Contractor 5. Address <br /> TYPE OF WELL/PUMP; License No..__�Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> P INSTALLATION ❑ SYSTEM-14" IR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC K SEWER LINES <br /> DISPOSAL FLD. PROP. !!NE <br /> FOUNDATIO AGRiCULTU ELLOTHEA WELL PITS/SUMPS <br /> INTENDED USE TYPE'OF WELL OBLEM AR CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial LJ Open Bottom [2% a Dia. of Well Excavation <br /> ❑ Domestic/Private '0 Gravel Pack ❑ Tr Dia. of Well Casing <br /> Type of Casing Specifications <br /> ❑ Public ❑ Other elta th of Grout Seal <br /> Approx. Dept ❑ Eastern Surfac at Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction L2 Well Diam r Sealing Material (top 50') <br /> Depth Filler Material (Below 50') 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E2REPAIR/ <br /> ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial— Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> Type/Mfg �Crs�ryr Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation ; <br /> 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 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well foundation } <br /> DISPOSAL PONDS ❑ Property Line <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."Contractors 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 shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic�otau st call f a requirod inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 8 Oce), <br /> Area O <br /> Pit or Grout Inspectio nrl <br /> te Final Inspection by <br /> Date i <br /> Additional Comments: r C-te-*7 <br /> ❑ 5tk 466-6781 0t1369-3621 .Manteca 823 04 ❑ Tracy 835-63135 <br /> Applicant- Re urn iall copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk.,, CA 9,5201 <br /> 13 f vlu l S 4- r i�e d <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY D PERMIT NO. r f <br /> + EH 1324(REV,t i e s{ r� f //A_ ,,!` <br /> EH 1428 y/�n / �,/ �7/ <br />