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APPLICATION FOR PERMITS <br /> SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> j 1609 E. HAZELTON AVE,STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> w PERMIT EXPIRES 1. YEAR FROM DATE ISSUED" <br /> rx (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 applical is <br /> I 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 S <br /> Local Health District, <br /> 1 ' M <br /> an Joaquin <br /> �� • � dfi ca u, r� 6 <br /> Job Address ©l ` �} Us-¢ C� <br /> ,E, <br /> C y P <br /> �.. it of Size M <br /> Owner's Name "��j� ` L \(/� Address" 0� - <br /> �� ti,� Phone 2 (� <br /> Contractor Address <br /> TYPE OF WELL/PUMP: License No. -"Phone <br /> NEW W9LL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> P INSTALLATION ❑ SYSTEM.R IR LJDISTANCE TO NEAREST: SEPTIC �K OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIO AGRICULTU ELLx <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE"OF WELL OBLEM AR CONSTRUCTION SPECIFICATIONS <br /> I <br /> ❑ Industrial ❑-Open Bottom ❑' a Dia. of Wel! Excavation <br /> ! ` Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack ❑ Tr <br /> Tyne of Casing Specifications <br /> ❑ Irrigation <br /> Q Public ❑ Other elta <br /> th of Grout Seal Type of Grout <br /> _�gpprox ?Dept ❑ Eastern Surfac al Installed by <br /> Repair Work Done ❑ Type-of-PumpH.P. r <br /> State Work Done <br /> Well Destruction _ <br /> ❑ Well Diam r{ Sealing Material (top 50') <br /> Depth ! Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> =--, f Na septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial_ available within 200 feet.) <br /> Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ <br /> SEPTIC TANK F Water table depth <br /> Type/Mfg <br /> PKG. TREATMENT PLT. [I Capacity_ No. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line C— <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ; Total length/size <br /> ❑ Distance to,nearest: Well 'Foundation <br /> � Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS - - <br /> ❑, Distance to nearest: Wel! Foundation <br /> DISPOSAL PONDS ❑, t Property Line f ;d j-Y <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 /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: y L <br /> Per <br /> employ any person in such manner as to become subject to-workman's c'ompensation_aws of California."Contractor's ormance of the for 'hiring of sub-contracting ch this permit is issued, lsignanot <br /> turre <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 applic st call f a regairad inspections. Complete drawing on reverse side. <br /> Signed i <br /> a Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by .. � 4 <br /> Date Area � <br /> Pit or Grout Inspectio ate <br /> { Final Inspection by i Date <br /> Additional Comments: '4ill <br /> ❑ Stk 466-6781 ❑ L di 369-3621 t ❑ Manteca 823- 04 ❑.Tracy 835-6385 � 4-e" JG <br /> I <br /> Applicant Re urn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,,P.O. Box 2009, Stk., CA 95201 . <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CK- k = <br /> INFO -- - " CASH RECEIVED BY p PERMIT-NO. t" <br /> + EEH H1 -24fREV.4 ��.� _ /J _ �� C', i <br />