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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I'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 sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> __ q {,, <br /> \CJ� 1 I'1 Er City ��- Lot Size X f PM <br /> �( Job Address (] <br /> / Owner's Name ►, )r 31 \�C Address L0 C' Phone <br /> �C Contractor Address License No. Phone_ <br /> I r TYPEtOF W_ ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ._ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL a,ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL REA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom anteca —4-Well Excavation Dia. of Well Casing <br /> Ll Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications <br /> ['1 Public ❑ Other ,» F] Delta Depth of Grout Seal Type of Grout -- <br /> I I Irrigation Approx. epth I 1 Eastern rface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. "' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTIO al o septiablec system <br /> rented if public sewer is Z <br /> t <br /> Installation will serve: Residence_,.Y._,,,Commercial„___,Other T__.—�.»...,..�- Mme---q-- --Y---,�• <br /> Number of living units: Number of bedrooms v <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC"fCapacity� ❑ Type/Mfg y No. Compartments <br /> C <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> € Property Line <br /> Distance to nearest: "Well Foundation P Y <br /> t <br /> LEACHING LINE ❑' No. & Length of lines Total len gthlsize ' <br /> FILTER BED ❑ ' Distance to nearest: Well Foundation `Property Line <br /> SEEPAGE PITS 11 Depth Size Number } <br /> t SUMPS D' Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ k <br /> I herebyx8ertify that I have prepared this application and that the work will be done in accordance with San Joaquin co#'nty ordinances, state laws, and <br /> rules and f6gulations 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: "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 applicant must cel for all rp qui ed inspections. Complete drawing on reverse side. <br /> r <br /> rigned X Title: Date: <br /> FOR DEPARTMEN{TI'IU.SE ONLY <br /> Application Accepted by . Date ` Area <br /> I Pit or Grout Inspection by Date Final Inspection by - Date <br /> Additional Comments: O <br /> j ❑ 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 85201 <br /> a <br /> FEEAMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. <br /> INFO 7 <br /> +.EH 13-24 IREV.i i H 51 3�. � '�17 <br /> EH 14-20 <br /> tt <br />