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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) 4.6-6781 <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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> ' C��' G�-� City S' reO`U Lot Size PM <br /> Job Address <br /> �4_0wner's Name 2 T Address�lT Gam.-7�� Phone <br /> r <br /> ~`�-" License No. Phone <br /> Contractor st_/ Address <br /> TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> } PUMP INSTALLATION ❑ SYSTEM REP OTHER ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELLMM <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open BottomDia- of Well Excavation Dia. of Well Casing <br /> r <br /> ❑'Domestic/Private ❑ Gravel Pack Type of Casing Specifications <br /> I'Public Cl Other Depth of Grout Seal Type of GroutI I Irrigation _..Approx. DeptSurface Seal Installed byRepair Work Dane L7 Type of PumpState Work Done <br /> Well Destruction ❑ Well DiameterMaterial (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1.1 DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet-) <br /> Installation will serve: Residence Commercial— Other <br /> S Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS L`1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> Y 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." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X. l `�!�- Title: Date: — <br /> FOR DEPARTMENT USE ONLY C <br /> Application Accepted by Date A Area <br /> Pit or Grout Inspecti / Date Final Inspection by atm <br /> Additional Comment �369362�10 <br /> � — �" n' �� n �"fStk 466-6781 ❑ Lodi Manteca 823-7104 ❑ Tracy 5- 5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> R <br /> i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"ND. <br /> INFO <br /> L� <br /> + EH 13-24 iREV.I/n 51 {j,� � �� �p�"-' Q 7 <br /> EH 14-26 <br />