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.. , APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—I ON AVE., STOCKTON, CA �L�L \�` <br /> Telephone (209) 466-6781 <br /> iPERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> b (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. <br /> Job Address v City Lot Size-P PM <br /> Owner's Name Address til V` 1 Phone / •u <br /> Contra ior� 1 Address-_f = ^—a - °^^-"I icense No: 3­71f-1360 <br /> ' ne?Y —0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> " ✓ ��' PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ <br /> DISTANCE.TO NEAREST: SEPTIC TANK Sf VIfER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION 4GRIICLTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL �PROBi�ilkl AR CONSTRUCTION SPECIFICATIONS❑ Industrial ❑ Open Bottom Ma Diaof Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack;�..,;�,. .Trac T i <br /> y e _.,,__...—Type of � � Specifications <br /> ❑ Public , ❑ Other ❑ Delta Depth'of Grout Seal Type of Grout <br /> ❑ Irrigation �Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. > State Work Done I <br /> Well Destrut ction ❑ WdDiameter Sealing Material atop 501 n <br /> .I Depth - Filler Material (Below 501 '• �Vy 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AD TIO DESTRU TION (No septic system permitted if public-sewer is U <br /> k 4 available within 200 feet.) i <br /> Installation will serve: Residence Commercial_ Other. t <br /> Number of living units: Number of bedrooms <br /> m <br /> Character of soil to a depth of 3.feet: s Water table depth <br /> SEPTIC TANK ❑ Type/.Mfg tcapacity No. Compartments „(1 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance tonearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines = -''` Total.length/size <br /> i <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i ❑ D'epth_ $tie _ ! Number <br /> SUMPS ❑ Distance to nearest: Well '`k T rFoundation Property Line I <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 subject to workman's compensa- <br /> tion laws of'California." I <br /> r The applicant must tali for,.gil required inspections. Complete drawing on reverse side. . - ; ` <br /> i <br /> Signed Title: Date: T <br /> FOR DEPARTMENT USE ONLY.-,,. y� <br /> t `��' % ' <br /> Area <br /> A <br /> Application Accepted by Date— ____ - <br /> Pit or Grout!Inspecton by �. Date_ .. Final_Ins ction_by_ _ Date _18 <br /> Additional Comments: k <br /> I'] Stk 466-6781 ElLodi' 369-3621 ❑ Manteca"823-71041 © Tracy 83546385 <br /> Applicant- Return all copies'to: Environmental Health Permit/Servioe'a i601 i Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> `i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-241REV.i/a51 C C, ��rt 2t{-Cf7 <br /> EH 14-28. L <br />