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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j 1601 E. HAZEL T ON AVE,, STOCKTON, CA <br /> I Telephone (209).466-6781 Q <br /> 111 PERMIT EXPIRES 1 DATE ISSUED YEAR R M <br /> O <br /> i (Complete in Triplicate) <br /> { <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 /> Job Address �Q Ci Lot Size PM <br /> 4 p� <br /> Owner's Name /� �_A-,& JWC f—s� Address <br /> � —Tf�•� - Phone <br /> Contractor F 4)a 6ozz4,1!Address 4qfi� 22 "1 41 License N Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> • <br /> DISTANCE TON SEPTIC TANK SEWER LINES �ObSAL . PROP. LINE <br /> FO TION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> - INTENDED USE TYPE OF WELL 0BLEM AREA RUCTION SPECIFICATIONS <br /> ❑ Industrial (� Open Bottom ❑ Mant Dia. of Well Excavation Ilia. of Well Casing <br /> ❑ Domestic/Private L2 Gravel Pack ❑ Tr Casing Specifications <br /> ❑ Public ❑ Other Delta Depth of Grou T <br /> ❑ Irrigation _Approx Type of Grout <br /> pth ❑ Eastern Surface Seal Installed by <br /> Work Done ❑ Typ ump H.P, State Work Done <br /> Well Destruction 103 ell Diameter Sealing Material (top 50') <br /> {' Depth Filter Material (Below 50') 0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITI <br /> ON ❑ DESTRUCTION {Na septic system permitted if public sewer is <br /> available within 200 feet.} <br /> Installation will serve: Residence— Commercial^ Other <br /> s 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 SEEPAGE PITS ❑ Depth Size Number <br /> r SUMPS ❑ 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 the San Joaquin Local Health District. <br /> f 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 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 /> t <br /> The applicant must call fo all require inspections. Complete drawing on reverse side. <br /> Signedel?"O!CATitle: Date: _;�z — 4a <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted btb . <br /> Date Area W <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> l <br /> _ Additional Comments: <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 EIVManteca 823h104 ❑ Tracy 835.63% <br /> 1 Applicant- Return all copies to: Environmental Health Permh/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE: AMOUNT-DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. <br /> INFO <br /> + EH 14-26 IR EV.1/8 51 � <br />