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v� <br /> APPLICATION FOR PERMIT y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 witWSan 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 /> �,/� 7�[� 1�1i City.�— Lot Size PM <br /> Job Address r4 <br /> y� I� + Phone <br /> Owner's Name _.I��� �y✓���"'LLL _ Address __ Q <br /> 3 License No3a152 Phone <br /> Contractor Address <br /> R E DESTRRUCTIO <br /> TYPE OF WELUPUMP:; o-•--,,,®: NEW,WELL` ❑. M-- <br /> ' <br /> _I� OTHER O <br /> PUMP INSTALLATION LJEPA R <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.I"f QR�• LINE r � <br /> A f.- <br /> FOUNDATION AGRICULTURE-WELL OTHER WELL PITS/SUMPS �5f <br /> f� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Open Bottom ❑ anteca MDia. of Well Excavation Dia:,of-W,eil Casing".` <br /> Type of Casing <br /> - Specifications j0f 44— <br /> Domestic/Private /-WGravel Pack ❑ Tracy yp g 4' <br /> ❑ Public Cl Ocher i ❑ Delta Depth of Grout Seal �f� -- _ Type of Grout <br /> Seal Installed by <br /> 11 Irrigation Approx. Depth I I Eastern SurfaceV , <br /> to Work Done <br /> Repair Work Done E Type of Pump <br /> H.P. ? <br /> Well Destruction D Well Dia r Sealing Material Itop i �J <br /> T <br /> De Filler Material IBe ow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIWADDITION 1 l DESTRUCTION l I (No septic system permitted if public sewer is <br /> I available within 20¢feet.) <br /> Installation will serve: 'Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> l PKG. TREATMENT PLT.❑ ,� "� �..�' <br /> f 3 istance to nearest: Well Foundation Property Line <br /> ------------------ <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size' <br /> FILTER BED ❑ Distancetto nearest: W Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> ' SUMPS V ❑ Distance nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C7 <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 f`aws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed lure ant's signa <br /> -:'— ture certifies the following I_certify that,in ibe performance of the-work.for which this permit is issued,,) shall not <br /> -- manner a'_ <br /> s to become subject to workman's compensation laws of,California."Contractor's hiring or sub-contracting signature <br /> employ any person in such <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 /> rf <br /> tion laws of California." "m `' <br /> 3 k The applicant m st ire inspect' omplete drawing on-rev a side <br /> Signed X s ' Title: - <br /> Date: 5 <br /> R <br /> FM DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by Gj <br /> Pit or rout spection by. Date < Final Inspection by Date F <br /> 999' Additional Comments:;. - s <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823- 04 ❑•Tracy 835-6385, <br /> Applicant-?Return all copies to: Environmental Health Permit/Services 1601 E: Hazalton Ave., P..0. Box 2009, Stk., CA 95201 . <br /> r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. <br /> INFO p� CASH <br /> + EH 53-24{REV.t/n sl ! O. 6D <br /> 4 EH 1428 <br />