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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (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 compliancewith San Joaquin Co linty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. r ,P <br /> t),2 k) <br /> Size ZQ N-Zd PM <br /> [+ City <br /> Job Address <br /> r3/— (� <br /> ;� <br /> r-r,,- Phone <br /> Owner's Name <br /> 4Addres-s <br /> —_ — Z <br /> N.AS� <br /> Contractor/ dress <br /> DESTRUCTION LJ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El _ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK� ; <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> ^ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weli Excavation Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack` _ '❑TFacy' w`�.`��`-TYpe of-Casingi <br /> (1 Public F1 Other F1 Delta Depth of Grout Seal <br /> Type of Grout ' <br /> I I Irrigation _ApprJ Depth II Eastern Surface Seal Installed by <br /> H P to Work one <br /> Repair Work Done- ❑ Type of Pump I <br /> Well Destruction ❑ Wel! Diameter Sealing Material (top 50'1 <br /> ` filler ateri'I (Below 50'i <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I /REPAIRIA DITION LI t DESTRUCTION { I available-w%dhin 200 feet(No septic-systern .) if public sewer is <br /> k !! <br /> Installation will serve. <br /> Residence* Commercia _ Other ' <br /> �,. <br /> Number of living units: y Number of bedrooms <br /> Character of soil to a depth of 3 feet r rater table depth <br /> + i <br /> rtments <br /> SEPTIC TANK —E] Tyle/Mfg/Mfg city No. Compaq ' <br /> 0 Method;of Disposal' <br /> PKG. TREATMENT PLT. El <br /> " <br /> Distancet to nearest: ell Foun6TYZ-' Property Line <br /> LEACHING LINE Li No. & Llength of line,- Total IengthLsize ti <br />" FILTER BED ❑ Distance to nearest: Well "� yFoundationn II�_ Prop y Line <br /> t ! Size " Number <br /> SEEPAGEIPITS I Depth ` <br /> SUMPS <br /> L�� Distance to Weare t: Well/l���"Q— Foundation �_PMi3s,Y 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, 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'sulject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call for all uired inspe tions. Complete drawing on reverse side. ., <br /> Title: <br /> Date: <br /> Signed <br /> . <br /> �' R DEP fiTMENT USE ONLY / <br /> iPate Area <br /> ca ` <br /> i Applition Accepted by i <br /> Fk <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: s <br /> El 835-6385 <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t 1 <br /> FEE ' AMOUNT DUE"—` AMOUNT'REMiTTED CA5H CK —7RECEIVED BY "DATE PERMIT NO. <br /> + EH 13-24iREv.1/n5) r - r <br /> EH 14.26 <br /> 1. ' <br />