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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 7 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 /> N � �f/ City •, Lot Size P <br /> `Job�Address M ,. <br /> Owner's Name'dl _ Address. "7- ' Phone <br /> Contractpr� rAddress :;j�4License iVa ~a Phone <br /> TYPE QF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> usn�/kf PUMP INSTALLATION ❑ # ,SYSTEM REPAIR ❑ OTHER El <br /> (DISTANCE TO'NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONSt <br /> € r , -❑-Industrial_ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private ❑ GraveF Pack ❑ Tracy A Type of Casing Specifications <br /> Cl Other r d' 1- Delta Depth of Grout Seal Type of Grout <br /> it I Irrigation t ' —•.-Approx. Depth I 1 Eastern Surface Seal Installed by _ <br /> 'Repair Work Dorie 13 Type-of Pump H.P. State Work Done`'"'"i-- <br /> Well Destruction ❑ Well Diameters Sealing Material (top 5011 <br /> Depth Filler Material.(Belo i $ <br /> d <br /> +� TYPE OF SEPTIC WORK: NEW INSTALLATION i.l REPAiRiADDITION [r DESTRUCTION I ) Mo septic system permitted if public sewer is <br /> C - available withiri•200 feet.) <br /> t <br /> tnstallation will serve: . Residence— Commercial_ Other <br /> I :{" Number of living units: Number of bedrooms <br /> { Character of soil to a depth of 3 feet: A Water`table depth <br /> roe ?-SEPTIC TANK ❑ Type/Mfg f.0, ' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal _ <br /> y, Distance to nearest: ell Foundation ' ' SProperty.Line <br /> BLEACHING LINE ❑ No. & Length of linesA2 Total length/size t c <br /> M I `..F..ILT_ER BED ❑ Distance to nearest: on Property Line <br /> ' j0--SEEPAGE PITS 11 Depth 2- Size Number <br /> SUMPSLl Distance to nearest: Well Foundation 4 Property Line t <br /> DISPOSAL PONDS ❑ <br /> t 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, an <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, )shalt 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 vuork for which this permit is issued, I shall employ persons subject to workman's compensa- t <br /> € •—tion laws of California." <br /> - <br /> t,, k The applica ust call for required inspections. Complete drawing on reverse side. <br /> __' I a-� <br /> 3 , Signed' -- Title: Date: <br /> 'FOR DEPARTMENT USE ONLY <br /> Appkkion"Accepted by W — . -.: Date `U Area f <br /> .:r.,,.Pit or Grout Inspection b Date Final Inspection by Date <br /> a-a-F <br /> " Additional Comments: <br /> El Stk 464-6781 ❑ Lodi 369-3621 0anteca 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 /> INFOFEE AMOUNT DUE AMOUNT REMIT ED GK RECEIVED 8Y DATE PERMIT'NO. <br /> CASHS' <br /> ♦.EH M24(REV,t i K 5) <br /> EH 1129 �. ..s..a. ; <br /> l <br />