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~' APPLICATION FOR PERMIT <br /> w SAN JOAQUIN LOCAL HEALTH DISTRICT No <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES'1 YEAR FROM DATE ISSUED V <br /> ;•(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 <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 /> .City 1�4/VLot Size PM J <br /> Job Address � - <br /> � IrOwner's Name - SO Address �Q Sp• C .1ofG Phone " r/ V <br /> Contractor �L Address License No. Phone <br /> i <br /> TYPE OF WELL/PUMP: NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ( � <br /> PUMP IN 1 TLON ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSFLD. PROP. <br /> FOUNDATION A LTURE WELL OTHER�AL <br /> PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C <br /> PECIFICATIONS <br /> ElIndustrial ElOpen Bottom ElManteca a. of Well Exc n Dia. f Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack LL] Type of Casing Specifications <br /> y - <br /> ❑ Public 'El Delta Depth of Grout Seal Type of Grout 1 <br /> � <br /> El Irrigation! �p epth ❑Eastern Surface Seal Installed by ' <br /> r x <br /> Repair Work Dane ❑ T of Pump H.P. State Work Dol ne <br /> Well Destruction Well Diameter Sealing Material {top 501 <br /> } Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is <br /> i �f available within 200 feet.) <br /> i <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 t Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ is Method of Disposal <br /> Distance to nearest: "''Well Foundation r Property Line <br /> LEACHING ONE— Ci No. & Lefigth'of lines ~ Total length/size <br /> FILTER BED ❑ Distance o+to nearest: Well Foundation ° Property Line <br /> H �� f <br /> SEEPAGE PITS ❑ Depth + Size ' Number <br /> SUMPS ❑ Distance"to nearest: . Well Foundation -Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be do i e 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 far which this permit is issued, I shall not <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." A <br /> Th cant ust call for all required i pections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR Dl�eARTMENT USE ONLY 4.1 <br /> Application Accepted by �>�[' } 'ul w _ `" ' _ r Date -a v Area <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: P i; <br /> ❑ Stk 466-6781 ❑ Lodi 36913621 ❑ Mante 823-7104 ❑.Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95201 l <br /> FEE AMOUNT DUE. ` AMOUNT REMITTED _ K RECEIVED BY DATE PERMIT ND. <br /> INFO ' <br /> + EH 13-241REV.i <br /> EH 14-2a <br />