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APPLICATION FOR PERMIT <br /> �- �� $;�._ ,m ire -r�<r•, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELiON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 'PERMIT EXPIRES 1-YEAR FROM DATE ISSUED } , <br /> {Complete in Triplicate} <br /> .This <br /> cation is <br /> Application is hereby made oJoaquin San <br /> County Ordinance Local <br /> No.District49 for sewage or(No. 1862 for t to construct <br /> 549 and the Rules and hereinall the work R Regulations of he San t Joaquin <br /> made in compliance with San <br /> Local Health District. <br /> .. <br /> �r City Lot Size PM <br /> Job Address <br /> Address Phone <br /> Owner's Name <br /> lrt - . <br /> Contractor <br /> Address C icense No. �13Q �Phone <br /> ""'NEti7V"1IVEL"L WELL REP�ACENIENT`❑ DES�ITCTIONJ❑ <br /> --TYPE-OFWCL'L/PUMP: >• SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LAVES <br /> DISPOSAL FLD. PROP. LINE h" <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> – <br /> __,I.NTENDED_USE �— TYP-E-OF-WELL =P-ROBL"EM-AR EA-- CONSTRUCT'ION-SPECIFIC-ATIONS---�- <br />'I - Dia. of Well Casing <br /> f ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> w Type of CasingSpecifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp <br /> Type of Grout <br /> 1:1 Public C1 Other ❑ Delta Depth of Grout Seal yp. <br /> ° ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H.P. State Work Done <br /> I Repair Work Done ED Type of Pump ; <br /> Well Destruction EI Well Diameter Sealing Material (toj 501 <br /> Depth -❑ Filler Material ;Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-0 'REPAIR/ADDITION ❑ DESTRUCTION available within ed if public sewer is <br /> 200 eettl <br /> 'Installation will serve: Residence Commercial— Other <br /> ` Number of living units: Number of bedrooms F Water table depth <br /> Character.of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ "Type/Mfg <br /> Capacity <br /> .- Method of Disposal <br /> - PKG. TREATMENT PLT, EJ , <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> a LEACHING LINE ❑ No. & Lengthy, f lines- <br /> 'IF " �} Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Number <br /> SEEPAGE <br /> SEEPAGE PITS El Depth Sizel <br /> SUMPS ❑ Distance to nearest: Well /Foundation Property Line <br /> DISPOSAL PONDS ❑ .^ ,+± � �'` '-~ �- � ' "r <br /> I hereby certify that I have prepared this application and that the work will.be-donein-accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin-Local Health District. work for which this permit is issued, I shall not <br /> Nome owner or licensed agent's signature certifies the following: "I certify that in,the pe_ <br /> formance of the <br /> employ any person in such manner as to become subject to workman's compensatiori laws of California." Contractor's hiring or sub-contracting signature <br /> C ifies the following:""I certify that in the performance of thework for which this permit is issued,I shall employ parsons subject to workman's compensa- <br /> tio of California.' „� , <br /> The applic t call fo all re fired• pecii s.' plate drawing on reverse s' e. R- <br /> Signe <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date <br /> Application Accepted by <br /> ,i A Area <br /> — Date <br /> ;jDate Final I spection by ! <br /> -: Pit or Grout Inspection by <br /> 4A4 <br /> Additional Comments: <br /> .Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 AMOUNT DUE AMOUNT REMITTED <br /> RECEIVED BY DATE' PERMIT"NO. <br /> INFO _ nJ <br /> + EH13-24(REV.t/6 5) <br /> EH 14-26 - - ' <br />