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fA. <br /> APPLICATION FOR PERMIT <br /> l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> - Telephone (209) 466-6781 <br /> l� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> :l <br /> (Complete in Triplicate) <br /> i <br /> Application is hereby made to the San Joaquin Local Health District for a' lations of lite San Jooaqpermit to construct and/or install the work fierein described.This applic aq is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Reguuin <br /> Local Health District. <br /> 7"fJ ` Lot Size PM <br /> Job Address - <br /> i Few , - Phone 7—�U <br /> i — Owner's Name �—�� 69 1AZ Address <br /> IZO <br /> r Contractor�� <br /> J Address Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION LJI PUMP INSTALLATION ❑ SYSTEM REPAIR>V/l� n <br /> Ia,e THER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS n1 <br /> INTENDED USE :!TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r <br /> L] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I ❑ Industrial <br /> T of CasingSpecifications <br /> ) omesticlPrivate ❑ Gravel Pack ❑ Tracy Type T of Grout <br /> k .❑ Public O Other E3 Delta Depth of Grout Seal Type <br /> ❑ Irrigation __Approx. Depth ❑ Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump <br /> H.P. �j State Work DonefGji <br /> Well Destruction ❑ Well Diameter Seating Material Itop 501 <br /> Depth Filler Material [Below 501 <br /> 4 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (Nosbavaptic system <br /> in emitted if public sewer is Z <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: Wat pth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t 1, <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well oundation Property Line <br /> LEACHING LINE ElNo. & Length es Total length/size <br /> 1 FILTER BED C Dis to nearest: . Well- Foundation Property Line ✓" <br /> I SEEPAGE PIT ❑ Depth Size Number <br /> SUMPS ❑illDisrt�ance to nearest: Well Foundation Property Line <br /> OSALPONDS ❑ 1 <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 <br /> rules and regulations of the Sars—Joaquinlocal Health District. <br /> Home owner or licensed agent's sibnature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> ram,employ any person in such'mabner_a's to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> k 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 /> I tion laws o`f California." i! ) <br /> i Tfie <br /> applicant , I req a it x ns. Complete drawing on re rse e. _ <br /> ... <br /> Signed I s Title:— Date: t <br /> { <br /> _ FOR DEPARTMENT USE NLY <br /> :r iS <br /> Date Area <br /> Application Accepted�by l <br /> iDate Final Inspection byDate <br /> Pit or Grout Inspection by: <br /> Addmonal Comments: <br /> ❑ Stk 466-6781 ❑, Lodi -3621 ❑ Manteca 7104 ❑Trikei <br /> Applicant - Return all copies to: Environmental-Health.P.ermit/Services 1601 E. Hazeln A1�a.�P� <br /> • Box 2009, Stk., CA 95201 <br /> FEE CK9:i� <br /> CEIVED SY f- ATF�•--p°R'� "PERMIV-NO. <br /> INFOAMOUNT DUE_T AMOUNT REMITTED C,gS ,�-- <br /> + EH 13-24(REV-t/a51• U� � L T�`�`�V <br /> EH 14.28 . <br />