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APPLICAJION FOR PERMIT <br /> �f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> VWV , 1601 E. HAZE LTON AVE., STOCKTON,•CA <br /> Telephone.(209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED c= , <br /> n i ri <br /> w= ' tion is <br /> (Complete in Triplicate) <br /> .This <br />` ca <br /> Application is hereby made to the San Joaquin0 Local Hance No.District549 for sewage or{No. 1862 fart to ewell and/orinstall <br /> atnd thQiRules and{Regulationnss of he San Joaquin <br /> a 1 <br /> made in compliance with San Joaquin County _,f• x ter, F <br /> Local Health District. •� <br /> l a P <br /> Job Address <br /> L �� � City Yr LL4Se;se s <br /> 4�L(�} r k V1 Address <br /> �- :Phone <br /> Owner's Name <br /> Phoria <br /> Contractor's Name License No. <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTAUCTiON.❑ " r <br /> TYPE OF WELLIPUMP: •,OTHER,0 <br /> SYSTEM REPAIRV N r ,, <br /> I PUMP INSTALLATION ❑ "• ` <br /> DISPOSE1LaFLD N <br /> DISTANCE TO NEAREST: SEPTIC.TANK_ SEINER LINES, -- PIT PS .� <br /> FOUNDATION AGRICULTURE WELL OTHER WEIL <br /> INTENDED USE TYPE OF WELL PROBL� EM AREA CONSTRUCTION SPECkFICATIONS F ,p{a of WBII Casing <br /> E <br /> 0.Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing -Spec) Ptlons <br /> $,DomesticlPrivate ❑ Gravel Pack ❑ Tracy YP , Type of Grout <br /> I ❑ Public <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> [I Irrigation __—Approx. Depth Eastern Sulf e Seal Installed by <br /> k H.P. State Work Dpne <br /> Repair Work Done �{ Type of Pump ng Material (top 50'1 <br /> Well Destruction ❑ Well Diameter SeFilalinger <br /> {Below 50') h <br /> Depth <br /> Pei <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ alvail bllelwth ne20b feet lgd if public sewer is <br /> i <br /> installation will serve: Residence— Commercial_ Other , <br /> Number of living units: Number of bedrooms <br /> 1 Water(_able depth <br /> Character of soil to a depth of 3 feet: Capacity Na: Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal.'- <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: WBII Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of,lines` Property 4ine r <br /> FILTER SED L1 Distance to nearest: Well. Foundation— <br /> 0 Depth Size'- Number <br /> E SEEPAGE PITS Pro a Line.� <br /> SUMPS ❑ Distance to nearest: . Well Foundation .P.rtY <br /> DISPOSAL PONDS ❑ ty.` ces, state laws, and <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sash Joaquin coon sordmap <br /> l not <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or ice in such manner torbecome subject Ito workman's kman's compensation llowing: "I certify that in the awsofCal-iforniahe Corinacto�r`sih ring 0 sub-cont act ng signatureissued, I <br /> employemploy any pe _ <br /> emplcerties the following:"i certify that s the performance of the wank for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> i in <br /> tion laws of California." , ` <br /> cfio . Compl drawing on <br /> side. R <br /> The appli m call for all require Pe yr/ } <br /> r Title: !` x Date ` } <br /> Signed <br /> ORD _A TMENT USE ONLY <br /> ~ Data <br /> Application Accepted by '+' pC��2� <br /> Pit or Grout Inspection by _ Date <br /> ' Date <br /> Final Inspection by <br /> Additional Comments: " <br /> ❑ Stk 466 6781 ❑ Lodi 1 O'Manteca <br /> "823=7104 ❑ Traey 83r :CA <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P O 80x,2009,Stk <br /> CK RECEIVED BY HATE PERMIT.'lVO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 1324(REV.10l831 �S (r>Ira <br /> EH 7426 <br />