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9 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) grq. 04* <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 /> Locai Health Distri�ct. <br /> C �. L <br /> City Lot Size PM <br /> Job AQdress <br /> _ Phone �w <br /> Owners Name Address -- <br /> Contractor / V_ Address £3Lou_ License No. hone�JL� <br /> TYPE OF WELL/PUMP: NEW WELL O t ,off * WELL REPLACEMENT ❑ DESTRUCTION Ell <br /> PUMP INSTALLATION ❑'f t. I SYSTEM REPAIR ❑ OTHER EI <br /> DISTANCE TO NEAREST:_ SEPTIC TANK SEWER LINES ' _ DISPOSAL FLD._-.- PROP. LINE <br /> 'FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> INTENDED USE TYPE OF,WELL Y� PROBLEM AREA _CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial L Open Bottom of Well Excavation r_ Dia. of Well Casing <br /> ❑ Domestic/Private Ci Gravel Pack C Tracy Type of Casing Specifications <br /> f Public 71 Other n Delta Depth of Trout Seal Type of Grout <br /> Irrigation Approx. Depth I I Eastern Surface Seal Installed by_. / - j <br /> Repa r Work Done L3 Type of Pump H.P. State Work Done V <br /> Well Destruction ❑ Well Diameter ' rSealing Material (top 50"1 <br /> Depth o Fiie'r Material£.( ole 50')' <br /> TYPE-OF-SEPTIC•WORK:—NEW'INSTALLATION I I REPAIR/ADDITION DESTRUCTION 1 1 (No septic system permitted if public sewer is <br /> available within 200 feet_)I <br /> Installation will serve: Residence I.__— Commercial Other' r _r# >� .I <br /> Number of living units: Number of bedrooms ' t <br /> Character of soil to a depth of 3 feet: I l�f <br /> Water table depth!._ <br /> SEPTIC TANK O Type/Mfg __ .'��e Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ �i+ r Method of Disposal <br /> - { - Distance to nearest: Well-, r 'Foundation Property LineOE <br /> _. <br /> LEACHING LINE No. &Length of'li6s —__7I_— I _ TQtat length/size � <br /> FILTER BED f a ❑ Distance to nearest: { Well tom"`-� Foundation ' Property Line <br /> SEEPAGE PITS I Depthj A^ 1 Size Number <br /> 1 � <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line__— <br /> } , DISPOSAL PONDS O + y= <br /> { I hereby certify.that I have prepared this application and that the work lwill be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and.regulations of the San Joaquin Local HealthDiltrict. <br /> Homo 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 followi "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 Calif m <br /> The applica s calffor requir ecti te-drawing on erre side? _ <br /> Signed X <br /> 1 ,�} R DEPARTMENT USCONLY <br /> Application Accepted by '_ ._ Date Area <br /> Pit or Grout Inspection by 4 ate --- Final Inspection by Date_ <br /> s <br /> Additional Comments: _ <br /> C Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 O 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 /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. <br /> _ INFO CASH <br /> + EH 13-241REV,tin51 � •.�1��3 ^� <br /> EH 14-2e '7' <br />