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�., APPLICATION FOR PERMIT <br /> �. '. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA C5 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the Sari 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:Gounty 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 /> Job Address City Lot Size PM <br /> �GEric�[ ± Ph __ T <br /> I Owner's Name Address <br /> . <br /> 0�4QCon tractor Address License a Ph <br /> TYPE OF WELL/PUMP:. .. JNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Q ,- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> kDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI <br /> ❑ Industrial ❑ Open Bottom ❑. Manteca Y „Dia.-of_Well Ex pia. of Well Casing <br /> C-1 Domestic/Private ❑ Gravel Pack ❑ Tracy T asing Specifications <br /> i f"1 Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I irrigation Approx. Depth astern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of H.P. State Work Done <br /> Well Destruction ❑ e I Diameter r Sealing Material (top 50'I <br /> Depth �# v;;y Filler Material (Below 501 =' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 1-1 DESTRUCT, (No septic system permitted if public sewer is <br /> + available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other � <br /> i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a'depth of 3 feet: Water table depth <br /> r SEPTIC TANK �❑ TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Q.• Method of Disposal <br /> z <br /> Distance to nearest: . Well Foundation Property.Line <br /> LEACHING LINE ❑ No. &"Length of lines. ' r Total length/size <br /> FILTER BED ❑ Distance to nearest:? Well j Foundation Property Line <br /> SEEPAGE PITS FI Depth l -'Sire Number <br /> SUMPS L-1 Distance to nearest: Well Foundation Property Line <br /> i DISPOSAL PONDS ❑ <br /> G I hereby certify that I have prepared#his 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 /> The applicanust call for all required i spections. Complete drawing on raver a si��_ <br /> I Signed Title: Date: <br /> t. <br /> FOR DEPARTMENT USE-ONLY <br /> • 43 <. <br /> Application Accepted b Date JArea <br /> Pit or Grout Inspect y Final Inspection byC-L�C/Ls� Date <br /> Additional Comments: / <br /> ❑ Stk 466-6781 ❑ Lod 369-3621 C7 Manteca 823-11W4 ❑ fracy 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 /> +.EH13-24(REV.i/M5) <br /> EH 14-28 <br />