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i <br /> _�•'�'' APPLICATION.FOR PERMIT <br />` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTaON AVE., STOCKTON, CA O GvL &ux�' <br /> i Telephone (209) 466.6781 <br /> f PERMIT EXPIRES 1 YEAR_FROM DATE ISSUED ©L-D P ref <br /> ,_�tr�: v (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. r ' <br /> Job Address > _?,/✓O . : 8 � Cit � f � <br /> ! y,Z Lot Size ti7LJ PM <br /> Owner's Name ��r/�� / r� Address <br /> Phone <br /> Contractor y! Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> h PUMP INS ± CI <br /> ❑ SYSTEM REPAIR ❑ OTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL PROP. LINE <br /> FOUNDATION A URE WELL ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA, CON ION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca \f ra. of Well Ex ion Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> C7 Public ❑ Other elta Depth of Grout Seal Type of Grout <br /> li ❑ Irrigation ---Approx. th ❑ Eastern r, Surface Seal Installed by ? <br /> Repair Work Done ❑ Type ump H.P. State Work Done <br /> Well Destruction ❑ ell Diameter Sealing Material {top 501 p <br /> Depth I Filler Material (Below 50') N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ . DESTRUCTION; (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:.I t E <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mf <br /> g CapacityNo. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line f <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED T C7 Distance to nearest: ` Well' Foundation <br /> �+. Property Line <br /> i f t . <br /> SEEPAGE PITS ❑ Depth r Size �` t - ' <br /> - Number <br /> SUMPS ❑£ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> i <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 I <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." 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." `T <br /> T licant mus al for all ired nspections. Complete drawing on reverse side. <br /> Signed X Title: Date: Q <br /> FORD PARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection b Date Final Inspection Date3 <br /> Additional Comments: _P�7 �� .; <br /> ❑ Stk 466 67$1 ❑ Lodi 369-3621, ❑ Ma 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE. PERMITNO. <br /> EH 3-24(REV.rix5] <br /> EH 1426 <br />