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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 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 d <br /> Local Health District. <br /> Job Address <br /> + t,�� CiltykAm Lot SizePM <br /> t a nl. N, h 9 -53 <br /> Owner's Name off& Address . Phone <br /> Contractor Address License No. Phone <br /> TYPE OF,WELLIPUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR i] OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC T>E� PR <br /> SEWER LINES DISPOSAL FLD. PROP. LINE L <br /> FOUNDAAGRICULTURE WEL OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OFEM AREA STRUC710N SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private n. ❑ Gravel y Type of Casing Specifications <br /> M Public ❑ Othero ' Depth of Grout SealType of GroutIIrtiyation -Apprern Surface Seal Installed by Repair Work_pone—O--Type of-PuN.P. r� - State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 O� <br /> Depth �� Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is <br /> available`•wi6n 200 feet'.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units_: Number of b drooms r <br /> Character of soil to a depth-of`3 { <br /> — feet; I Arr /w C <br /> ater table depth ' <br /> SEPTIC,TANK El - Capacit No. ompartments <br /> t <br /> I PKiG..TREATMENT PLT. ❑ 3 Method of Disposal <br /> Distance to nearest: Well I )fT Foundation Property Line F ._._.. <br /> -LEACHING LINE No. & Length of lines Total length/size <br /> 40 Pr vi <br /> FILTER SED ❑ Distance to nearest: Well&29 Foundation L-_ Property Line <br /> z n <br /> SEEPAGE PITS Depth Size Number <br /> 1, t <br /> UMPS LD Distance to nearest: Well A)i FT Foundation Property Line FYI FT <br /> I <br /> DISPOSAL PONDS CJ t <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." <br /> The applicant must call for all required inspections. <br /> in_ssp_e_c_tions. Complete drawing on reverse side. <br /> Signed X� � Title: ' Date: _ / > l sl 7 <br /> I <br /> F MENT USE ONLY ` <br /> Application Accepted by Date y V Area /�� <br /> /f t or Grout Inspection by Date Final Inspection by ///l _ Date LL <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 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 /> FEE AMOUNT DUE AMOUNT REMITTED A H RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-241REV,1/85) � 7u ,�j <br /> EH 14-26 <br />