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v� h <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT %..A r <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA No <br /> Telephone (209) 466-6781 p <br /> PERMIT EXPIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate)App <br /> /or install the work herein describe . <br /> is <br /> cat!nis <br /> madlecnticompliance with SanoJoags nthe San County OrdinaJoaquin lncle No.549 for sewage or h District for a permit <br /> 1862 for cwell/pump and the Rules and R gulations of tlhe San l Joaquin <br /> Local Health District. <br /> `7 _S'il C' dr City_S'>i(�i� Lot Size PM <br /> Job Address ��-x --+ <br /> Owner's Name <br /> �gss Phone <br /> Contractor S ---Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL F] WELL REPLACEMENT ❑ DESTRUCTION ❑ r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I-] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/ PS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIE <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of el cavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications <br /> [1 Public ❑ Other elta Depth of Grout Seal Type of Grout <br /> I I Irrigation <br /> __AP epth { I Eastern `Surface Seal Installed by <br /> Repair Work Done ❑ e of Pump N.P. State Work Done <br /> Well Destruct- ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 RI=PAIRIADDITION 1.1 DESTRUCTION available'within 200 feet.) if public sewer is <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: Water table depth <br /> SEPTIC TANK ❑ 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 lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS f 1 Depth S�a 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 done 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 for 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." <br /> Thea �ficant st call for all required inspec ions. Complete drawing on reverse side.�` 45 f Ok---) <br /> Date: <br /> Signed Title: <br /> 1_ <br /> F�EPARTII ENT USE ONLY <br /> Application Accepted by <br /> Qmh/'\ DateA;�� <br /> - Area <br /> Pit or Grout inspection b Date Final Inspection by Date <br /> r. <br /> Additional Comments: �✓ "' ' �Y' <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma ca 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 /> 4 <br /> FEEPZ <br /> DUE AMOUNT REMITTED UK itRECEIVED fay DATE PERMITNO. <br /> INFO f_—S-7 <br /> / ��{`EH13-24MEV-1/n51 Or' s ST `' / <br /> EH 14-2e <br />