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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> +. <br /> PERMIT EXPIRES 1•YEAR FROM DATE ISSUED <br /> r (Complete in Triplicate) application is <br /> Joaquin <br /> Local Health District for a permit to construct and/or install the work herein described. This <br /> Application is hereby made to the San Joaq Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County <br /> Local Health District. f e; PM <br /> r � � tat Size ' <br /> Job Address / j. <br /> Phone <br /> A dress <br /> I Owner's Name <br /> License No.� Phone <br /> 1 Address a 3 <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION LJNEW WELL ❑ OTHER ❑ <br /> TYPE OF,.WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. T <br /> EAREST: 5E 'PT1C TANK SEWER LINES �-- PITS/SUMPS <br /> DISTANCE TO N �� AGRICULTURE WELL OT <br /> H <br /> FOUNDATION --� <br /> SPECIFICATIONS— b <br /> INTENDED USE TYPE OF WELL PROBL� �EM AREA CONSTR Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca of Well Excavation <br /> •El Industrial Specifications <br /> ❑ Domestic/Private - ❑,Gravel Pack <br /> ❑ Tra Type of Casing Type of Grout <br /> r Delta Depth of Grout Seal <br /> f-I Public ~' f 1.Other <br /> ' Depth i I Eastern Surface Seal Installed by <br /> I I Irrigation State Work Done <br /> e of Pump _�-- H P' <br /> Repair Work Done 0, yp r _ Sealing;Material (top 50'1 <br /> Well Destruction O Well Diameter _ <br /> Depth , Filler Material '1 <br /> _{Below-50 �- <br /> DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION i a REPAIRJADDITION available within 200 feet.) <br /> { Installation will serve: Residence Commercial, Other. �..� <br /> { <br /> t Number of bedrooms - I Water table depth <br /> Number of living units: _ ` <br /> Character.of soil to a depth of 3 feet: r "r Capacity 1 x as- Ot' No. Compartments <br /> Type/Mfg ' " <br /> SEPTIC TANK f It € Method of Disposal <br /> PKG- TREATMENT PLT. ❑ 1 k � Property Line <br /> 0 r r; � <br /> Distance to nearest: Well <br /> __ Foundation d-- <br /> iD Total length/size + <br /> No. & Length LEACHING LINE P< No. of lines Property Line r r � <br /> FILTER BED ❑ Distance to nearest: Well_ — Foundation -- <br /> ' n Oti <br /> Size Number <br /> SEEPAGE PITS .Depth WellFoundation !O <br /> SUMPS Ll Distance to nearest: ��— <br /> Foundation� Property Line <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, an <br /> rules and regulations of the San Joaquin Local Health District. <br /> g <br /> ., shall <br /> he <br /> e-6f li�e work for <br /> ch <br /> F{ Home owner or licensed h manse gas to become sub eco lto wing: "I certif mpensation lawsofCalifornia." Contractor'srhiring t orr sub-contracting s permit is issued, l signatu�e <br /> r employ any person m arsons subject to workman's comQensa- <br /> certifies the following: "I certify that in the pertormance of the work far which this permit is issued, I Shall employ P f <br /> tion laws of California." <br /> The applicant m call for all required in ctio s. Complete drawing on reverse side. <br /> Date: 40 <br /> - Title: u <br /> Signed X <br /> F DEPAIRTMENT USE ONLY ` <br /> r r� <br /> �j Area <br /> Date <br /> Application Accepted by <br /> - Date <br /> Final Inspection by ti Date <br /> Pit or Grout Inspection by <br /> :k `t <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lolth Permit/Services 1601 E. Hazelton Ave., P.O. Bo <br /> Lodi '369-3621 ❑ Manteca 823-7104 E3 Tracy 835-6385 <br /> Applicant- Return all coQies di Environmental Heax 2009, Sik., CA 95201 <br /> CK RECEIVED By DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REwTTEO ASH <br /> INFO f9 CA <br /> + EH 13-24(REV.I/H 5� <br /> k EH 14-2a <br />