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i <br /> APPLICATION FOR PERMITS <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �+ a <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) V <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 /> Job Address l <br /> ' 7 City Lot Size PM <br /> Owner's Name Address f <br /> Phone S <br /> Contractor Address <br /> TYPE bF WELla/PUMP NEW WELL ❑ License No. _Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> —'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE-TO NEAREST: SEPT[ K OTHER ❑ <br /> SEWER LINES DISPOSA PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ONSTRUCTION SPECIFICATIONS <br /> ED industrial ❑ Open Bottom anteca Dia. 11 Excavation <br /> ❑ Domestic/Private ❑ Gra ❑ Tracy Dia. of Welf Casing <br /> f-7 Public C1 Other CType of Casin1 Delta g Specifications _. <br /> Depth of Grout Sea[I I Irrigation ---Approx. Depth I 1 Eastern TYPe of Grout <br /> Repair Work Done ❑ T Surface Seaf Installed by <br /> Type Pump H,P. State Work Don <br /> Well Destruction ❑ Wel[l Diameter <br /> Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i I DESTRUCTION rl (No septic system permitted if public sewer is <br /> Installation will serve: ~Residence_ CommercialOther available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: u <br /> SEPTIC TANK ❑ Type/Mfg Water tahle depth <br /> r <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: WellTotal length/size <br /> Foundation Property Line <br /> t <br /> SEEPAGE PITS I 1 Depth <br /> Size Number <br /> SUMPS L7 Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation Property Line _ <br /> I hereby certify that I have prepared this application and that the work will <br /> rules and regulations of the San Joaquin Local Health District. be done in accordance with San Joaquin county ordinances, state laws, and <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 shelf employ persons subject to work <br /> tion laws of California." man's cam <br /> Dense <br /> The applicant must call for all required inspections. Complete drawing on reverse side. ~ <br /> Signed XI. —_ r a <br /> Title: bate: II ', <br /> 10 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C n <br /> Pate_��—��-! Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by I <br /> Additional Comments: V Ski / Date <br /> Stk <br /> 466-6781 El Lodi 369- 621 T �S r r(f <br /> pplicant- Return all copies to: Environmental Health aPaemit/Sery Permit/Services E❑Hazelton Tracy AveP O Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY PATE <br /> PERMIT NO. <br /> t EH 13-24fREY:tirtsl vq pU lr - <br /> EH 11-76 l 1� `/s' I01a 3-70 <br />