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1 <br /> APPLICATION FOR PERMIT c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I 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 Ordina <br /> Local Health District. No. 549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin <br /> lj <br /> t Job Address s <br /> City Lot Size PM <br /> Owner's Name /`UO [3r7i7�lj S <br /> Address / q"l 7296 <br /> Phone <br /> Contractor Address <br /> 'License Na, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCENTO NEAREST: SEPTIC TANK SEWER LINES DISPOSA PROP. LINE <br /> FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS <br /> INTENDED USE TYPE 0 PROBLEM AREA TRUCTION SPECIFICATIONS <br /> ❑ Industrial 70pen Bottom ❑ Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Doutestic/Private PackTracy Typ in Specifications <br /> f 1 Public r Cl Delta Depth of Grout Sea Type of Grout _ <br /> I I Irrigation ! <br /> J pprox. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done Type of Purnp H.p- <br /> State Work pone_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth f Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION IN. septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation.will serve: Residences—Commercial ^ether- <br /> Number of.-living units: Number of bedrooms <br /> 1' Character-of soil to a depth of 3 feet <br /> "SEPTIC'-TANK�'� Type/MfWater table depthy <br /> Capacity P y No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> rE Distance to nearest: Well Foundation ` <br /> t Property Line <br /> LEACHING LINE Qi No. & Length of lines Total length/size <br /> FILTER BED ❑; Distance to nearest: Welt Foundation <br /> a I Property Line <br /> SEEPAGE PITS 1 1: Depth Size Number <br />• SUMPS ❑1 Distance to nearest: Well Foundation <br /> DISPOSAL PONDS C]1. <br /> Property Line <br /> I hereby certify that L 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 /> 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." f <br /> The applicant must 1 for all required inspections. Complete drawing on reverse side. <br /> t <br /> Signed X Title: Date: /6 �. <br /> - ., M <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Are <br /> Pit or Grout Inspection Date Final Inspection by 87 <br /> ` Date <br /> Additional Comments: 0-C7 '� $ <br /> ❑ Stk 466-6781 L7 Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT-NO. <br /> + EH 124 IFiEv.I/x slUK, <br /> EH 14-4-28 °� .. � G9U <br /> r <br />