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' APPLICATION FOR PERMIT 5 ✓ <br /> SAN .lOAQUIN LOCAL HEALTH DISTRICT <br /> .3 YG <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 k% <br /> i <br /> 1: (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 j <br /> y made in compliance with San Joaquin County Ordinance No.549 for sewa or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> ocal Health District. <br /> Job Address 1 �� . City Lot Size PM <br /> �d 1 1 <br /> Owner's Nam O [Q, A�GIr Address o /I Phone <br /> ontractor _" �L - Address License No. Phone_ I <br /> TYPE OF WELL/PUMP: NEW WELL ❑- WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER ❑ <br /> DISTANCE.TO NEAREST; SEPTIC TANK SEWER LINES ' PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ���PITS/SUMPS <br /> INTENDED USE TYPE OF"WELL .PROBLEM AREA STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Ma Dia. of.Well Excavation Dia. of Well Casing r <br /> r 'A❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> f'l Public I] Othe ❑ Delta Depth of Grout Seal Type of Grout i <br /> I l Irrigation __Approxi Depth I I Eastern Surface Seal Installed by. <br /> rI <br /> Repair Work Do Type of Pump H.P. State Work Done <br /> Well Destr ction ❑ Well Diameter Sealing Material (top 501 <br /> Depth 1 Filler Material (Below 50'), <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION A I DESTRUCTION Wo 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 ) Water table depth <br /> SEPTIC TANK .❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ l� �. _ _ Method of Disposal <br /> Distance to nearest:' Well "Fouridation ° Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 11 Distancetonearest: Well " TbUridation Property Line <br /> SEEPAGE PITS i I Depth 1 Size Number <br /> t. <br /> SUMPS ❑ .Distance'to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t� `"+ <br /> I hereby certify that I have prepared tliis 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, 1 shall not f' <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 /> The applicant must call for all re irk ed inctions: Complete drawing on reverse side. �r <br /> Signed X� � / J� GG1?'{° _ — Title: Date: /off <br /> 7. <br /> a° FOR DEPARTMENT USE ONLY i <br /> Application Accepted by Rate Area i <br /> Pit or Grout Inspection by Date F al inspection„y Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ' ❑ Tracy 835-6385 <br /> Applicant- Return all copies t f Envir nment I Heal h Permi ervice 1601 E. Hazelton Ave.,`P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUET AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +.EH 13-24lAEv'1/R5) <br /> EH 14.28 <br />