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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6:M44A0?j_3AZ(4 93'94 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y <br /> JComplete in..Tripljcate) <br /> aquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Jo <br /> nty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Cou <br /> Local Health District. `3.. <br /> (�`O Cit Q Lot Size PM <br /> Job Address " <br /> ge:t:-�W�-e, -eAddress <br /> Eerj��vacL�k� Phone <br /> Owner's Name <br /> Contractor <br /> Address License No. Phone <br /> TYPE'OF WELL/PUMP: NEW WELL (7 WELL REPLACEMENT ❑ DESTRUCTION 1:1 <br /> PUMP INSTALLATION ❑ SYSTEM REPA1 OTHER El <br /> DISPOSAL FLD. PROP- LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT5ISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> i <br /> r INTENDED USE TYPE OF WELL ROBLEM AREA CON UCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom Elanteca Di . of Well Excavation <br /> e of Casin Specifications <br /> ❑ <br /> Domestic/Private ❑ Gravel Pack L1Tra yP g Type of Grout—.-- <br /> n Public ❑ Other f7 Delta Depth of Grout Seal <br /> I <br /> I I Irrigation - — —.-Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump P. State Work Done <br /> Well Destruction El Well Diameter Sealing Mater (top 50'1 <br /> Depth Filler Material -'top <br /> 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 RFPAIR/ADDITION I 1 DESTRUCTION �af o septic systithinem <br /> permitted if public sewer is <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 ❑ 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 /> i <br /> SEEPAGE PITS I I Depth Size _ Number <br />{ SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> i 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 Cal"ornia." <br /> The appiica ust call far all requiredeons plete drawing on ieverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date Arearp <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date final Inspection by Date �3 <br /> f Additional Comments: � - GA �f <br /> D Stk 456-6781 °❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑,Tracy 835-6385 ►-+off � r <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNE AMOUNT REMITTED CASH <br /> INFO � .,SEH 13-24(REV.+�rs 51 3 S3�• U� <br /> EH 14-26 - - <br />