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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> `' 1601. E: HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 'PERMIT,EXPIRES 1 YEAR FROM DATE ISSUED <br /> , ,,,(Complete in Triplicate); s <br /> P 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.sewagp or No..1862 for welt/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.-' d <br /> Job Address Ij� _ i n City Lot Six a R '0D PM' <br /> 1 <br /> Owner's Nam e✓ /GE'J �✓y/r �[. i/ 'Address 5 1At/ Phone <br /> r 7 <br /> t d <br /> Contractor Address License No. Phone 9,00 <br /> / <br /> TYPE OF WELL/PUMP: NEW WELL ❑'- —WELL REPLACEM T '0' -DESTRUCTION ❑ � <br /> PUMP INSTALLATION ❑ SYSTEM­REPAIR ❑ " " " -OTHER``❑ <br /> DISTANCE TO NEARES SEPTIC TANK SEIER LINES DISPOSAL FLD. PROP. LINE <br /> t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t <br /> ID Domestic/Private ❑ Gravrel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public i ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation I ----Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth I Filler Material lBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION_ ,❑l, REPAIR/ADDITION ❑ DESTRUCTION V (No septic system permitted if public sewer is <br /> available within 200 feet.) nn <br /> Installation will serve: Residence_ Commercial Other, <br /> Number of living units:' { Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ T r <br /> ype/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ t s� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line L <br /> ' LEACHING LINE ❑ No.'& Length of lines � _Total length/size`' } <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lie r/t <br /> SEEPAGE PITS ❑r Depth r Siie. Number r <br /> SUMPS ❑ Oistanceirtd nearest: Well Foundation %P'I"��—Prioperty Line 1u <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 /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which,this permit is,i'ssiued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractoes 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 call for all r inspections. Complete drawing on reverse side. <br /> c ! , <br /> Signed Title: '� � Date: ._� <br /> FOR DEPARTMENT USE ONLY �f <br /> Application Accepted byy ,Date.F -. f Area 4 <br /> Pit or Grout inspection by Date Final Inspection by Date � <br /> Ad itional Comments: <br /> 5tk 466-Ml ❑ Lodi 369-3621 ❑ Mifnteca 823-7104 ❑ Tray 835.6385 <br /> Ap#icant - Return all copies to: Environmental,Health.Permit/Services 1801 E. Hazelton Avg., P.O. Box 20091-Stk.,'CA 95201 -- y <br /> FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED 8Y DATE PERMIT'NO. <br /> INFO <br /> a, <br /> + EH 13-24 1REV.1/a 51 <br /> EH 14.28 ' • b 1 �!�0�� <br />