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I <br /> APPLICATION FOR PERMIT C r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED A-?>- <br /> i (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. III, + Ir I <br /> City r Lot Size PM <br /> Job Address 11 <br /> Address Phone <br /> Owner's Name <br /> II <br /> /alQ n <br /> Phone L, �- <br /> (�F Address License No. TL <br /> Contractor_Ag� WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: I� NEW WELL ❑ OTHER <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El <br /> DISPOSAL F PROP. LINE <br /> DISTANCE TO NEAREST: SEP`TIC TANK SEWER LINES ELL PITS/SUMPS <br />' FOTYUNDATION. AGRICULTURE WELL_ <br /> 4' <br /> INTENDED USE PE OF WELL PROBLEM AREA CONST N SPECIFICATIONS� pia- of Well Casing <br /> 1 ❑ industrial ❑ Open BottomL2t��of <br /> f Well Excavation <br /> Casing Specifications <br /> ❑ DomesticlPrivate ❑ Gravel PackType of Grout <br /> l'1 Public, ❑ Other FI Delta Depth of Grout Seal <br /> I 1 Irrigation —1I'Approx.-Depth I I Eastern Surface Seal Installed by <br /> ¢ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Sealing Material stop 50'1 <br /> Well Destruction ❑ Well Diameter g <br /> Depth Filler Material (Below 50'1 <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l i DESTFIUCTIONX <br /> i vo septic system <br /> 200 feetitled if public sewer is <br /> Installation will s'erv�:. Reslll�ence� Commercial— Other— <br /> Number <br /> ther <br /> 4living-units: <br /> Number of bedrooms <br /> j Number of living units: 1 <br /> f .T.— �..�..- Water table depth <br /> r Character of`soil'to`a depthlof 3 feet: �i �} <br /> ❑ 'T a/Mf ' Capacity No. Compartments <br /> SEPTIC TANK YP f3 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I 1 <br /> Distance to nearest: Well 'Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size f <br /> FILTER BED EJ Distance to nearest: Well # Foundation Property Line <br /> r <br /> SEEPAGE PITS 11 Depth Size Number <br /> Property Line n <br /> SUMPS L1 Distance to nearest: Well Foundation P Y l _ <br /> DISPOSAL PONDS ❑ <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 laws, and <br /> j 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 n t <br /> employ any person in such manner as to b'ecome'sobject'tii sivofknian's-cbrnWrTgatiori laws'of-Caiifi4r`Fi1a. CUntractor's hiring or sub-contracting signature <br /> I 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." II <br /> The applicant mus call for A required ins ctions. Complete drawing on reverse side. <br /> Tit1e: --�d?� _ Date: <br /> Signed X q <br /> I� FOR DEPARTMENT USE ONLY q <br /> -R l <br /> Date <br /> Application Accepted by4y�etdd, 4 a� <br /> pat <br /> Date Final Inspection by <br /> Pit or Grout Inspection by °I! <br /> � �p <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies)to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Silk., CA 95201 <br /> RECEIVED BY <br /> DATE PERMIT NO . <br /> FEE OUNT DUE AMOUNT REMITTED CASH <br /> INF {' <br /> +.EH13-244REv.rik5) t3�1r =- -a'�1��� <br /> EH 14-26 �� - <br />