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APPLICATION FOR PERMIT <br /> a� SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 1601,E. HAZEL T ON,AVE., STOCKTON, CA <br /> Telephone`12091 466-6781 v <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 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 Addr;me <br /> Ctty <br /> PM <br /> _ li <br /> Owner's �' Address . ione — 1�Contiactddress License No.,%2m Phone"���� <br /> TYPE OF WELL/PUMP: I NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION © !� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE. <br /> I€ <br /> FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INT NDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l <br /> I r <br /> ❑ dustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> estic/Privatevel Pack ❑ Tracy Type of Casing Specifications <br /> ublic ❑ Other ❑ Delta :Depth of Grout Seal Type of Grout <br /> ❑ Irrigation \rAPprox. Dept ❑. stern ace Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done ► {� <br /> I rV <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> ' <br /> Filler Material (Below 50) j 1 I1 <br /> Depth <br /> TYPE OF SEPTIC W RK: NEW INSTALLATION 11REPAIR/ADDITION ElDESTRUCTION ❑ (No septic system permitted if public sewer is i! <br /> available within 200 feet.) f <br /> t 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 I <br /> SEPTIC TANK ❑ s TypelMfg * Capacity No. Compartments I� <br /> PKG. TREATMENT PLT. ❑ " y Method of Disposal <br /> Distance to nearest: Wel! Foundation Property Line <br /> ! Tota! len h/size <br /> � LEACHING LINE ❑ No. & Length of lines length/size <br /> FILTER BED ❑ ' Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ '� Depth Size Number iF <br /> k SUMPS ❑ ;� Distance to nearest: Well Foundation _ Property Line <br /> DISPOSAL PONDS 0 <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 reguI ti an Joaquin Local Health District. !! <br /> Home owner icensed agent 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 rsort insuch man er as to become subject to workman's compensation laws of California."Contractor`s hiring or sub-contracting signature <br /> certifies th following: "l certif at in a perfor nee of ork7ingon <br /> ich this permit is issued,I shall employ persons subject to workman's compensa <br /> tion laws f Californi ." <br /> The appli ant mus or it requ' I dr <br /> Signed Title: "�/`� Date: <br /> FOR DEPARTMENT USE ONLY <br /> ° Asea s i <br /> Application Accepted b - owl 7 1AA^ Date JIMA <br /> Pit or Grout Inspection Date Final Inspection by-7 <br /> y �7ate; <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant- Return all copies`to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk:;-CA 95201: <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE ""'+ PERMIT�NO. <br /> INFO CASH <br /> + EH t3-24 MEV.1/e 51 - 1Y, 7 I,o-tit <br /> 1 1 <br /> EH 14-28 <br /> I � <br />