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APPLICATION FOR PERMIT 1� eit <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 5 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA r <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 compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1862 for weJI/pump and the Rules and Regulations of the San Joaquin <br /> Local health District. <br /> Job Address C It, <br /> Size PM <br /> Owner's Name Address Phone e�l <br /> Contractor <br /> Address License No. Phone <br /> 172'PE OF WELL/PUMP: NEW-WELL D WELL REPLACEMENT El DESTRUCTION 0 <br /> PUMP INSTALLATION SYSTEM REPAIR C1 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES — DISP;�O�SAL LINE <br /> FOUNDATION AGRICULTURE WELL ----- WELL <br /> _—G.T-H WELL PITS/SUMPS <br /> INTENDED USE TYPE OF:�VELL PROBLEM AREA Cam3l AvUCTION SPECIFICATIONS <br /> Ll Industrial El Open El6ttom [11 Mi ntec Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private E Gravel Palick Type of Casing <br /> I "_P_Tra��y Specifications <br /> n Public Other P Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation <br /> rox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done Lj_-- ype�ofPump H.P, State Work Done <br /> i �'Il.D <br /> Well Desiructi 0 Well Diameter <br /> Sealing Material (top 50') <br /> Depth <br /> Filler Material Melow 501 <br /> TYPE OF SEPTIC WO NEW iNSTALLATION I n[PAIR/ADDITION I.I DESTR(JCTIOY\(NO septic system permitted if public <br /> sewer is <br /> available within 200 fedt.� <br /> Installation will serve: Residence Commercial— Other 0 <br /> Number of living units: — NuWber of bedrooms <br /> Character of soil to a depth of 3 fee Water table depth <br /> SEPTIC TANK 0 Type/Mf.gl Capacity— No. Compartments <br /> PKG. TREATMENT PLT. EI <br /> f I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No: & Leirgth of lines Total length/size 7_5 <br /> FILTER BED 1-1 Distance'to nearesc Well Foundation — Property Line <br /> SEEPAGE PITS 11 Depth —Size Number <br /> SUMPS Ll. Distain"�Ito nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS El <br /> I hereby certify that I have prepared tinis 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 Diltrict. <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 t0become 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 /> Ch!applicant m�al$f 11 re uirad'inspections. Cg"Ip�ate drawing on reverse side. <br /> Signed Title: 49�_ k <br /> — :,r - - Date: <br /> F7ZM1,AENT USE ONLY <br /> Application Accepted by A: Date Area <br /> Pit or Grout Inspection by Date Final Inspection byz�L a. Date <br /> Additional Comments: +keviotk S- _��enmti_ See- k—' r zcc/ <br /> Z <br /> L1 Slk 466-6781 Ll Lodi 369-3621 0 Manteca 823-7104 El Tracy 835-6385 /__6 <br /> Applicant - Return all copies to! Environ'mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box <br /> Stk., CA 94T <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 9--j- <br /> INFO CASH RECEIVED BY it)A�TE 'PERMIT'NO. <br /> EH 1 3-24(REV.I I A 5) 0 <br /> EH 14-26 <br />