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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 y <br /> 1PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED <br /> (Complete.in Triplicate) <br /> �. :. <br /> mit to construct and/or install the work herein described. T <br /> Application is hereby made to the San Joaquin Local Health District for a per <br /> his 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. -Yr <br /> () T A `� :t City f Lot Size S6 PM <br /> Job Address .. , q - n <br /> �� Phone �[ <br /> it <br /> Owner's Name " <br /> IAddress License No. Phone <br /> onUactor� ¢ — " <br /> TYPE OF WELLIPUMP: NEW WELL CJ <br /> REPLACEMENT 11 DESTRUCTION ❑ <br /> PUMP INSTAL ON ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION " AGRICULTURE WE OTHER WELL PITS/SUMPS <br /> TYPE-OF_WEL•L- =P 09LEMAR@A NSTRUCTION—SPECIFICATIONS I <br /> INTENDED U$E_ - —Dia-"of-Well Casing' M : t' i <br /> ❑ Industrial ❑ Open Bottom ❑ me Dia;,of Well Excavation. <br /> Tof Casing Specifications 1 <br /> ...<.� �-.O-Domestic/Private---F] ype Gravel Pack ❑ y Type of Grout \ �} <br /> ❑ Public <br /> LJ Other Delta -Dept of Grout Seal vvv <br /> ❑ Irrigation ----Appro11 1 x. <br /> ❑ Eastern Surface Seal Installed by <br /> H. State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Se--ling Material Itop 501 <br /> " Depth Filler Material (Below 501 - --- 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DE5TRUCTIO INo septic system permitted if public sewer is <br /> + �....�.-� available within 204 feet.) <br /> Installation will serve: Residence f Commercial` Other <br /> l <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: I , <br /> Capacity No. Compartments ,1 <br /> SEPTIC TANK ElType/Mf� t Method of Disposal <br /> PKG. TREATMENT PLT, 1-1 <br /> Distance to nearest'. Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distancelto nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth I Size Number <br /> SUMPS ❑ Distance to nearest: Well 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, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> t 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 /> j 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:"1 certify that tri the performance of the work for which this permit is issued,I shall employ persons subject to workman's corn nsa- <br /> tion laws of California." I <br /> The app77RX����� <br /> ll required <br /> inspectionsComplete drawing on reverse side. <br /> Signed <br /> itle: Date: <br /> JF <br /> FOR DEPARTMENT USE ONLY <br /> Date � Area_O <br /> Application Accepted by ]„�Qcq <br /> I VL <br /> Date4'�.Sl <br /> Pit or Grout Inspection Date Final In pection by <br /> Additional Comments: F" <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I FEEAMOUNT DUE AMOUNT REMITTED ASF( RECEIVED BY DATE PERMIT"NO_ <br /> INFO <br /> + EH 13-24 IREV. /is 51ol <br /> LEr �7— ' <br /> b, <br /> EH 44-28 - ' <br />