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Z <br />fo <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />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? tt�� <br />uAp{ Hation is <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the M � r an � Joaquin <br />made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the u e i u11a"Ti' prwr+�+ <br />Local Health District. <br />t.r� City of Size <br />Job Address _ ��. <br />Owner's Name <br />Address Phone <br />NUG 2 310?9 <br />14 - <br />Contrac <br />TYPE 7 WELL/PUMIP -- :kms NEW <br />PUMP INSTALL, <br />- = DISTANCE -TO NEAREST: -SEPTIC TAN0', <br />FOUNDATION _ <br />Address <br />License No. Phone <br />PM <br />NELL„[J1- `W LL REPLACEMENT ❑ DESTRUCTION ❑ <br />TION El"� SYSTEM REPAIR ❑ OTHER 1-1 <br />r_SEWERh NE$ ��D'ISPOS_KC FLD.- PROP. L1NE�a. ' <br />AGRICULTURE WELL _' ""OTHER WELL PITS/SUMPS <br />IN DEQ USE TY OF. WELL PROBLEM AREA CONSTRUC_TION.-SPECIFICATI N- "` ---_z <br />ndustrial <br />Open Bottom_'EJManteca Dia. of Well Excavatio _ _ Dia of Well Casing <br />Type of Casin �`•'��Spec�fications <br />❑ Domestic lPrivate C3 Gravel Pack ❑Tracy yp g Type of Grout � <br />l"i Public D Other ❑ Delta Depth of Grout Seal ' <br />I Irrigation —.-Approx. Dept 1 Jastern iiSuur�rface Seal Installed by!4ZA <br />Repair Work Done ❑ Type of Pump H. H.P. —�C.' State Work Done <br />11 Sealing Material (top 50'1 <br />Wel! Destruction [D Well Diameter _ _�_- <br />Depth / Filler Material (Below 501 <br />WORK: NEW INSTALLATION I.1 REPAIR/ADDITION i 1 D <br />TYPE OF <br />Installation will serve: Residence _ Commercial <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />SEPTIC TANK ❑ Type/Mfg <br />;; PKG.,TREATMENT PLT.-❑'. -- � <br />iw �► s4`- <br />Distance to nearest: <br />Well <br />Other <br />N l 1 INo septic system permitted if public sewer is <br />available within 200 feet.) <br />! Water table depth <br />Capacity No. Compartments _ <br />Method of Disposal - <br />dation Property Line,— <br />Total length/size <br />LEACHING LINE Gi: 'No. &Length of lines � �� <br />FILTER BED ❑ . Distance to nearest: Well Jt, Foundation Property Line <br />.: 5EEPAGE`PiT;S- Depth T Size <br />7 Number <br />SUMPS LI Distance to nearest: wellxf° Fou Property Line <br />ND5 ❑ <br />E DISPOSAL PO <br />E I hereby certify that i have prepared this application 6d that the work will be one in accordance with San Joaquin county ordinances, state laws; and <br />rules and regulations of �th@#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 s issued, !shall not <br />employ any person in such manner as to become subject-to-workmaWs`Cotnpensation laws of California." Contractors 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 />1. The applicant m call for a1 requ' ins ctions. Complete drawing Z;:&i� <br />d <br />Signed X Title: � Date: <br />OR DEPARTMENT USE ONLY <br />Da� <br />te ` [ �Area <br />C q lication Accepted by ; dig <br />l�. Yj b <br />Pit or er, <br />`Inspe ion by Date Final Inspection by Date <br />!� Add'+tioCrt mets'' <br />❑ Stk 466-6781 ❑ Lodi 1 ` ; ❑ anteca 823-7104 ❑ TrabV Wb-bMU 2101 <br />Applicant Return all copies to: Erivirprjmentai Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 95201 <br />- C. <br />'FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y pATE PERMIT <br />INFO , X�:4 <br />EH 13-24" <br />EH 14-26 <br />