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APPLICATION FOR PERMIT <br /> SAN JOAQUINIOCAL HEALTH DISTRICT <br /> 1601 E. H4ZEL l ON AVE., STOCKTON, CA 5 <br /> Telephone IM91) 466-6781 a <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> y (.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. f <br /> Job Address r `f City, ! Lot Size PM <br /> Owner's Name �f�J � d4t__ Address fir- Phone ! <br /> c Contractor * Address Cicense No. f z`Phone , <br /> i <br /> TYPE OF WELL/PYMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> I LN <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C CTION SPECIFICATIONS <br /> a <br /> ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack. cy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation rox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done t <br /> Well Destruction ❑ Well Diameter l Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONV (No septic system permitted if public sewer is <br /> --available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other rj� l /���.-/ <br /> Number of living units: Number of bedrooms v v 17 J �--7 <br /> ` Character of soil to a depthof 3 feet: Water table depth <br /> ,SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ s I t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line` <br /> LEACHING LINEy'O�No�& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation. Property Line <br /> 4 . <br /> SEEPAGE PITS ❑ Depth; A Size Number <br /> S. SUMPS ❑ Distance to nearest:_. .,_Well t Foundation Property Line 4. <br /> DISPOSAL PONDS ❑ <br /> 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." 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 call for i ired ins ctions. Complete drawing on reverse 1 __— <br /> r Signed Title: �� Date: `? <br /> r r FOR DEPARTMENT USE ONLY <br /> 5 <br /> Application Accepted by Date. TCr I Area <br /> t Pit or Grout Inspection by J Date Final Inspection by (Date <br /> Additional Comments: .['\D -- <br /> ❑ Stk 466-6781 ❑ Lodi' 36'11 ❑ anteca 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO ...rrrrrr p <br /> + EH 13-24(REV,i/e sl <br /> EH 1418 <br />