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3 APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E 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 Sari'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 /> Job Addressy �'7�- _ CityLot Size /t �5� PM <br /> 1 <br /> Owner's Name I/�7// •J fir/ Address 7 T ' Phone <br /> r <br /> i Contractor P _ Address License No. Phone <br /> TYPE OF WELL/PUMP: I� NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PU STTA�ALLATION.❑ SYSTEM REPAIR ❑ <br /> E DISTANCE TO NEAREST: SEPTICTANK, SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL-- '� OTHER WELL PITS/SUMPS <br /> I INTENDED USE -(TYPE OF WELL..` PROBLE --CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom 0 eca of Well Excavation Dia. of Well Casing � <br /> ❑ Domestic/Private 0 Gravel Pack O Tracy Type of g Specifications a� <br /> ❑ Public 0 0th 0 Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Don Type of Pump. , H.P. State Work Done <br /> Well Destr ction ❑ Well Diameter " Sealing Material Itop 501 <br /> a< <r <br /> Depth Filler Materia! (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> I`, available within 200 feet.) <br /> ° Installation will serve: Residence_ Commercial_ Other <br /> I Number of living units: �� Number of bedrooms <br /> jCharacter of soil to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ 9 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> " LEACHING LINE ❑1 No. & Length of lines Total length/size <br /> FILTER BED D. Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth * Size Number <br /> SUMPS 01, 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 thePan 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.perforrrlance of the wbik for'which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica ust call for all req dins' io s. Complete drawing on reverse side. , <br /> Signed f Title: / ,ZJ � Date: <br /> r F D PARTMENT USE ONLY <br /> Application Accepted by iI Date` �� Area . <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 t Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6315 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> _FE E <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> + EH13-241REV.1i85) �" �♦ Q /�� <br /> EH 1428 <br />