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"` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE„ STOCKTON, CA �'k� <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 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 /> LJores—s- + r City Lot Size PAA Name y �+� �_ "`'fl 1� Address zion�0 �2� 1O� `� 7LJ65 <br /> f!torAddress License No. Phone;;�tm <br /> _ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ R ❑ <br /> DISTANCE TO NEAREST: SE TANK SEWER LINES DISP D. PROP. LINE <br /> I FOUNDATI AGRICULTURE WELL HER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL >-PRQ.5LEM CON TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottomra. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack of Casing Specifications <br /> F) Public ❑ Other Depth of Seal Type of GroutI I Irrigation —..Approx. DeSurface Seal Installe <br /> Repair Work Done ❑ Type of P H.P. State rk Done_ <br /> k Well Destruction ❑ Well eter Sealing Material Itop 50'1 <br /> Y D pthamFiller Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION l I DESTRUCTION><No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br />' Number of living units: Number of bedrooms .' <br /> , <br /> Character of soil toe <br /> a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to-nearest: Well Foundation Prooerty.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 Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> l 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 Diltrict. <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 u t call for II reqyim91 inspeeVons. Complete drawing on reverse side. <br /> I Signed X._ / Grpl��( Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> to Application Accepted by ry Date Z-11 Area <br /> k Pit or Grout Inspection by Date F pection by Date �� O <br /> Additional Comments: <br /> F ❑ Stk 466-6781 O 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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTEDLCSHCK RECEIVED BY DATE PERMIT•NO.+ EH EH 14-281REV.tiHsl � VV / <br />