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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - 1601 E. HAZELTON 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 boron described. phis application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and tpe Rules and tie � dons.of the San Joaquin t5- <br /> Local Health District. � , <br /> ;D <br /> Jab Address City 'S1ze 'W PM <br /> Owner's NameAdd <br /> Q� <br /> ress Phone <br /> Contractor's Name r�Y{/C - License No. r <br /> Pllong' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DES TRUCYION , <br /> PUMP INSTALLATION C1 SYSTEM REPAIR F ` r ?QTf�R L 1, <br /> DISTANCE TO NEAREST: SEPTIC TANK. t SEWER LINES; DISPOSAL FL D PROP LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL - ;-.PITS/$ jy}pg <br /> 14TENDED USE TYPE OF;WELL PROBLEM AREA. CONSTRUCTION,SPECIFICATIQNS <br /> ❑ Industrial ❑ Open Bottom '❑ Manteca Pia. of'Well Excavation ,Dia. of 1EVaII,Casing <br /> ❑ Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing Specrftions, <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Fypg of Grout _ <br /> ❑ Irrigation ---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 /> F Depth �— <br /> Filler Material (Below Io0'1 <br /> TYPE'OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTR Noseptic system"perri Itted`if'pu lic sewer is <br /> available within feef�l <br /> Installation will serve: Residence_ Commercial_ Other <br /> i <br /> Number of living units: Number of bedrooms I O <br /> Character of soil to a depth of 3 feet: Water table depth G <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 71Method of Disposal- G <br /> ` Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE r ❑ No. & Length of if nes Tptallength/size <br /> r O <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line $._. • I } <br /> DISPOSAL PONDS ❑ yr ': <br /> hereby certify that I have prepared this.application and that the work will be done in accordance with San.Jgaquin.county <br /> I� nCes;yiatrr' -as <br /> rules and regulations of the San Joaquin Local Health District. <br /> Hor'he-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-eompensation-lews-of-Californla-Gonlractor's hiring or subcontracting signature <br /> certifies the following:"I c ify that'in the performance of the work for which this permit is issued, I shall empluy`persons subject to-workman's compensa- <br /> tion laws of Californi ." <br /> The applicant for al require c'on . m le drawing on rever cle. > ' <br /> Signe <br /> Title: : / <br /> Date? <br /> FOR -DEPARTMENT USE ONLY <br /> Application Accepted by Date S <br /> 'Area <br /> - <br /> Pit or Grout Inspection by Date_ ,.` Final Inspectio y�. ;T Date t <br /> Additional Comments: ` <br /> ❑ Stk 466-6781...-., 0 Lodi 369-3621 - - ❑ Manteca -823-7104- -O Taacy-635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601E Hazelton Ave., P O 1�cr CA 96201. s"i <br /> yY <br /> a ° <br /> FEE AMOUNT DUE AMOUNT REMITTED r CCK ASH T RECEIVED BY ` <br /> INFO 1 DAtE PERMIT No. <br /> + EH 13-24IREV.10183) <br /> EH 14-28 - - ��/SS•S - ��5.- �� <br />