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APPLICATION FOR PERMIT <br />t�T + SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE I ON — AVE. STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />r install the <br />cation is <br />madec int <br />compliance writh Sari Joagiade to theS nn County ordinance Nto. 549 for sewage orJoaquin Local Healh District for a 't to construNo. 1862 for we Upuomp and the Ru s and herein <br />R gulations of the San' Joaquin <br />Local Health District. <br />t p <br />�. ,a r r I.�_� City _ rS Lot Size _�_ RC _ PM <br />Job Address ���� ' Y <br />+_ Address 2 ��.� R¢��`4--4 A( Phone_ <br />Owner's Name LA I s - <br />Contractor <br />Address _ <br />TYPE OF WELL/PUMP: NEW WELLJ WELL REPLA <br />PUMP INSTALLATION L SYSTEM <br />DISTANCE TO NEAREST: SEPTIC TANK _-_ — SEWFR 1NES <br />FOUNDATION AGRICUL <br />INTENDED USE TYPE OF WELL PROBLEM AREA <br />❑Industrial ❑ Open Bottom C Manteca <br />❑ Domestic/Private ❑ Gravel Pack ❑ Tracy <br />I Public 71 Other C Delta <br />L <br />_ License No. — � -_ Phone <br />`NT C DESTRUC 1 ION ❑ <br />AIR F1 OTHER ❑ <br />_ DISPOSAL FLO._ _— PROP. LINE <br />OTHER WELL PITS/SUMPS <br />ICTION SPECIFICATIONS <br />Gia. of -`Ilk" Excavation -- <br />Type of Casr — <br />Depth of Grout al <br />• I If <br />Dia. of Well Casing <br />Specifications <br />Type of Grout <br />I krigation _ Approx. Depth I I Eastern SunaeeSeal nsta <br />e of Pum P.e Work'DoneRepair Work Done L7Typ p <br />__ Sealri Material (top 50'1—Well Destruction ❑ Well Diameter 9r <br />Depth Filler Material (Below 50'1 <br />-REPAIRlAOD1TION <br />_. _ --- <br />, <br />I DIESTRUCTION I IeNailabD�'wsil tystem 't)cd if public sewer is <br />1YPE OF SEPTIC WORK: NEW INSTALLATiO <br />I Commercial — Other -12 4�>L-- t-•Installatien will serve: ResidenceNumber <br />tWatesth <br />of living units: �Number of bedrooms <br />if 0 <br />I <br />of soil to a depth of 3 teet:k—��NSEPTIC <br />_Character <br />❑ Type/Mfg b - Capacity_No. Cts--Methosal <br />TANK _te- <br />___PKG. <br />TREATMENT PLT. ❑;3 t7 Foundation <br />WCII � <br />—f Property Lin <br />Distance to nearest: <br />--LEACHING <br />Tot I le gthisize�aFILTER <br />LINE O No. &Length of lines <br />Well— Foundation <br />roperty Li -_ <br />BED ❑ Distance to nearest: <br />SEEPAGE PITS I Depth Size —._--- Number _ - <br />SUMPS '_l 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 Jo,rquin county ordinances, state laws, and <br />rules and regulations of the San Joaquin Local Health Diltrict. <br />that in the performance of the work :or which this permit is issued, I shall not <br />Home owner or licensed agent's signature certifies the following: "I certify <br />employ any person in such manner as to become subject to workman's compensation laws of California." Contrrctor'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 />The applicant must Call <br />for all required inspectionsomplete drawing on reverse side. <br />�Signed K es �_. Title: Date: <br />FOR DEPARTMENT USE ONLY <br />_ Date Area <br />Application Accepted by <br />Pit or Grout Inspection by Date <br />Final Inspection b� -e <br />Additional Comments: <br />C 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 CK RECEIVEO BY DATE PERMIT NO, <br />OUNT DUE AMOUNT REMITTED CASH <br />INF 0 <br />. EH 13-24IRGV-i/N5) ci,o <br />70, o o �; <br />EH t♦ -2e V <br />