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fS _ <br /> APPLICATION FOR PERMIT <br /> r. r' ' = t�4 : SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> -__ <br /> 1601 E. HAZtLIP �V :, STOCKTON, CA <br /> g L'A <br /> Telephone.(209) 466-6781 <br /> 3 1 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ��� <br /> (Complete in Triplicate) EN' rN, I 'VTAL HEALTH , <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ��1 'f1W45p6cation 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 /> 38 Job Address 0 City t Size PM <br /> nQ'i <br /> Ph <br /> Owner's Name 11✓t Address t]�f.� � �ti'' Phone - <br /> Contracto Address v l i -aJ License No.1 Lp(D-2-3(D-2-3 ?3 '+one (0 (--q <br /> TYPE OF WELL/PUMP: NEW WELL L1WELL REPLACEMENT ❑ DESTRUCTION 11til \ <br /> �k PUMP INSTALLATION ❑ SYSTEM REPAIR f� OTHER ❑ v <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIVES DISPOSAL FLD. PROP. EINE <br /> 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing <br /> Y YP 9 Specifications <br /> ❑ Public ❑ Other C1 Delta Depth of Grout Seal .*' � I <br /> Type Of Grout <br /> I I Irrigation / -Approx. Depth l I Ea tern ' Surface_ Seal Installed by <br /> Repair Work Done laP1" Type of Pump H.P. State Work Done U0 �- <br /> Well Destruction ❑ Well Diameter ! C <br /> Sealing Material (top 50') _ <br /> I Depth Filler Material (Below 501 <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION l I DESTRUCTION I 1 INo sepfic system permitted i1 public sewer is <br /> f available within 200 f eet.); !�• ; <br /> I Installation will serve: Residence— Commercial— Other ; <br /> Number of living units: Number of bedrooms f � <br /> Character of soil to a depth of 3 feet: Water tabledept I r <br /> SEPTIC TANK El T /Mf f " <br /> Type/Mfg Capacity No. Compartments - <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest; Well Foundation Property.Line <br /> LEACHING LINE ,_❑No._&,_Length_of_Iinas-_. __ _ _.Total..length/size-- _I <br /> FILTER BED ig Distance to nearest: Wel! �, 'Foundations" '� ` <br /> s ert <br /> } , Line � 1 <br /> 4 � tJ :;,'fit'.` � 'a" �`"'.y,`�: ..• _�..�,� ,.� .. � 3 <br /> r cJ li <br /> SEEPAGE PITS i i�,I r.Diith ` ? Sizet <br /> Number <br /> SUMPS 3 L� Distance to Aearest:1 Wel[ Foundation Property Line <br /> DISPOSAL PONDS )❑ "r } i 1 <br /> I hereby certify that I have preparcQ"ihis appficatioh and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulati o, Sari tloaquin.Local Health Dihtrict. } i <br /> Home owner teen ag is ignature.certifies the f owing: I cern that in the performance of the work for which itis f <br /> {{ g' permit is issued, 1 shall not <br /> employ any rcon in such nner as to bee me sdb' t workman's compensation laws of California.,,Contractor s hiring or sub contracting signature <br /> certifies the ollowing: Fl ce that i the o ca the work for which ermit is issued,I shall employ persons subject-to workman's compensa- <br /> tion laws Califomia.F' s <br /> The applic nt mus ca 1 all req red i mple drawing reve i 7 <br /> Signed <br /> Title: v <br /> Data• a <br /> FOR Df'EP MENT USE ONLY <br /> Application Accepted by Date �� � Area_ G� <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK <br /> NFO CASH RECEIVED BY DATE PERMIT NO. <br /> I <br /> +.EH 13-21(REV.1/K sl <br /> EH 11-26 <br />