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3 <br /> APPLICATION FOR PERMIT VV 3? ? <br /> 4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> ` T-elephorre`(266) .4.66-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " <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 Ryles and Regulations of the San Joaquin <br /> Local H�Ith District. I€ <br /> v <br /> Job Address <br /> City PM <br /> Owner'slNam t Address <br /> • hone <br /> a f q Z <br /> Contract mess License No.— [ hone 6 <br /> TYPE OF WELL/PUMP: '-4VEW:WELL& WELL REPLACEMENT ❑ DESTRUCTION i❑ <br /> !I� PUMP INSTAbLATl01V ❑ ! SYSTEM REPAIR l� OTH'E'RFO <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. :PROP. LINE " <br /> �f FOUNDATION AGRICULTURE WELL OT:HER.WELL yPITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIOIYSPECIF16 IONS 'ji'' s <br /> ❑ I s{`rial ❑ Open Bottom aManteca�"�"'-""'-Dia;o'f"Well Excavation 4 h ' <br /> Dia. of Well Casing <br /> ,�,��} estic/Private ❑ Gravel Pack ❑ Trac T e of Casin (� <br /> �� Y YP 9 Specifications <br /> *1' blic� ❑ Other ❑ Delta Depth of Grout Seal ' Type of Grout <br /> ❑ Irrigation pprox. Depth " ❑ stern Surface Seal Installed by <br /> Repair Wo rk Done Type of Pump, H.P. State Work Don'e' 4C 4 ,�} W <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 `— <br /> ��: Depth Filler Material (Below 50') j F <br /> TYPE OF'SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available_within 200 feet:j <br /> Installation will serve: Residence Commercial_ Other <br /> f <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: r <br /> Water table depth.` y <br /> SEPTICTANK ❑ Type/Mfg Capacity No` 6ompartme*1' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i Z <br /> LEACHI43 LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property'Line <br /> qr <br /> SEEPAGE: PITS ❑ Depth Size Number <br /> SUMPS I ❑ Distance to nearest: Well Foundation c ,' ' Y `— <br /> I 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 gpurity ordinances, state laws, and <br /> rules and Fegulat' s of the San Joaquin Local Health District. + s i. s <br /> Home owhe r license gent's signature certifies the owing: "I certify that in the performance of the work for-which ibis perrhit is issued, I shall not <br /> employ ar.. person in suc manner as to become su et o workman's compensation laws of California."Contractor's hiring„or""sub-contracting signature <br /> certifies t'e following: ^I rtify that in th If ce f the work for which this permit is issued, I shall employ,,persons'subject to workman's compensa <br /> tion laws of Califor ia." <br /> The appl leant ryfu ' 11 or all re ire Co awing on r s1 e. <br /> ee- <br /> Signedr t <br /> Title: Date: <br /> FOR DEPARTMENT'.USE-ONLY,' e i <br /> Applicatloi i Accepted by <br /> t�.r•.� 0� �)�` Q <br /> Date Area <br /> Pit or Grol t Inspection b "l • � , 5 <br /> Y Date < s Final Inspection by Date r�O.1 ' <br /> Additionalf 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 CK RECEIVED BY ,. „ DATE PERMIT NO. <br /> INFO CASH <br /> + EH13-241RM 1/65) <br /> EH 1426 ,,II S• o <br />