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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i~r <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 Health District. <br /> Job Address _I I q }Jli. 7 ° - 4 City()" ' ' Lot Size PM <br /> `�. �. <br /> _ Owner's Name Address - Phone <br /> Contract o Q Address "Q License NoVace—Phone L0 <br /> T_YPE OF'WE-LL. UMP: NEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I� 1PUMP INSTALLATION El SYSTEM REPAIR El - OTHER ❑ i <br /> DISTANCE TNEAREST: SEfT11C TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> O <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> k <br /> INTENDED.USETYPE OF WELL PROBLEM AR ASG-ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of a ation Dia. of Well Casing <br /> Specifications <br /> ❑ Domestic/?Private ❑ Gravel Pack ❑ Tracy Type of Casing P <br /> ❑ Public r ❑ Other ❑ Delta Depth of Grout Seal a of Grout <br /> ❑ Irrigatioq� ---Approx. Depth ❑ Eastern Surface Seal Installed by Co <br /> Repair Work Done ❑ Type of Pump H.F. State Work Dane 04 <br /> I Well Des6uction ❑ Well Diameter 1 Sealing Material (top 50'1 <br /> { <br /> i irDepth .1 Filler Material (Below 50') ` <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION ❑ EPAI /ADDITION Rr DESTRUCTION ❑ No septic system permitted if public sewer is <br /> �� � � p7va`able within 200 feet.) <br /> 1 <br /> Installation will serve: Residence Commercial_ Other <br /> Number of-0ing units`'% ,:Number-of edror oms <br /> t r - Water table depth�. ,�,,� I �.. <br /> Character of soil to a depth of 3'feeti , <br /> i <br /> SEIC TANK El Type/Mfge/Mfq Capacity <br /> 'pNo. Compartments <br /> PT / ' - !�� <br /> r <br /> PK43. TREATMENT PLT. ❑ r .• f Method of.Disposal <br /> f_ Distance to nearest: Well ' ', oundation Property Line <br /> t v: <br /> t - <br /> I <br /> LEACHING NE ❑ No. & Length of lines Total length/size L <br /> w <br /> FILTER BED E] Distance to nearest: Well Foundation Property Line — - <br /> SEEPAGE PITS l Depth Size Number t f{"+ <br /> SUMPS ;-- ❑ Distance to nearest: Well J,5� Foundation—1�. Property Line I <br /> DISPOSAL PONDS< ❑ ` <br /> hereby certify that hhave prepared this application and that the work will be done in accordance with San Joaquincounty ordinances, state laws,.and <br /> rules and regulations of the San-Joaquin-Local-Health-District. <br /> Home owner orficensed 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 /> F employ any persbn in such manner as to become subject to workman's compensation laws of California."Contractors 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 rnust�c�all for II r wired inspections. Complete drawing on reverse side.�� Date: <br /> ` G . V <br /> � Signed 'title: V. R <br /> 'title: - . <br /> ' y FOR D ARTMENT USE ONLY <br /> Application Accepted by <br /> Date • v Area <br /> 61ii or Grout Inspection by Date ' Final Inspection by Date <br /> Additional Comments: (! <br /> ❑ Stk 466$781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6:385 <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 CASH RECEIVED BY DATE PERMIT NO: <br /> INFO <br /> 4 . <br /> +EH 13-24(REV.1/R 5) <br /> EH 14-26 <br />