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AP (CATION-FOR PERMIT <br /> SA' OAn fIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON'AVE., STOCKTON, CA ' <br /> Y ' Telephone ( ) 466-6781 <br /> P RMIT PIRES 1,YEAR FROM DATE ISSUED <br /> a ) <br /> (Complete in Triplicate) <br /> Appli ironrs hereby made'to'the an quin Local Health Drstriet fora.permit to construct and/or install the work herein described. This appiication is <br /> dmads in ompiiance with San Jo County Ordinance No 549 for-sews <br /> pr No. 1862 for weitlpump and the Rules and Regulations of the San Joaquin <br /> • :Local Hes District <br /> f City. Lot Size PM <br /> Job Address ` <br /> 5 (/ Addressl/fT Phone <br /> Contractor Address License No. �Phone <br /> YPE OF WELL/PUMP -:s NEW-WELL'.0; WELL REPLACEMENT .❑ „DESTRUCTION ❑ <br /> ; . <br /> PUMP INSTALLATION SYSTEM REPAIR 11OTHfR O <br /> ISTANCE:TO NEAREST: SEPTIC TANK° SEWER LINES-1- DISPOSAL.FLd." PROP. LINE i <br /> FOUNDATION RICULTU OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE.OF WELL PROBLEM ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ©.Open Bottom -: ❑ Mant Die. of Well Excavation Ota. of Well Casing i <br /> Specificd'tions <br /> ❑ <br /> Domestic/Private <br /> '❑ Grave!Pack ❑ Type of fashlg _. <br /> 'r? Public Cl Other y Ito th of Grout Seal^ .,. Type of,Grout <br /> f I Irrigation - —Approx. Dep - I 1 Eastern Su Seal installad by <br /> Repair Work Oona -❑ ` Type of Pump <br /> H P. e <br /> ,. a Work Don <br /> Well Destruction . ❑ Well Diameter Sealing Material {top 50'1 <br /> Stat <br /> Depth ' Fillet Material (6elow 50'1' =' Q) <br /> TYPFOF SEPTIC WORK:-.:NEW INSTALLATION L1 REPAIR/ADDITION I ! DESTRUCTION available <br /> septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence l `Commercial``_ Other ' r <br />[ <br /> Number of,living units: Number oll bedrooms <br /> Character of sad to a depth of 3 feet: Water table depth <br /> r.. No. Compartments' r• <br /> 'SEPTIC TANK ❑ .TypelMfg Capacity <br /> PKG. TREATMENT.PLT.❑ r <br /> :_,_Method.of-Dispo 1 <br /> ` Distance to nearest Well Foundation K Property Line <br /> LEACHING LINE, ❑ No. &Length of lines Total length/size, <br /> FILTER BED ❑ .Distance to nearest: Well Foundation Property Line <br /> i SEEPAGE PITS. t I Depth Size Number <br /> F 1�' d <br /> F l ;. SUMPS I;1 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 accordanca with San.Joaquin'county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agents signature certifies the following:"1 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."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 must call for all required inspections. Complete drawing on reverse side. <br /> rQr�i/Ya/t Date. " d <br /> Signed X Title: <br /> r,. FOR DEPARTMENT USE ONLY U <br /> i Application Accepted Date Area / <br /> Pit or Grout Inspec n by Date Final InspectionAb5� Date <br /> 7 <br /> Additional Comments: AL <br /> ❑ Stk 466-6761 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 <br /> Applicant - Return all copies to: Environmental Health Porn All 1601 E. Haialton Ave.,P.O.Box 2009,.Stk., CA 95201 <br /> FEE MgUNT OUE AMOUNT REMITTED CASH RECEIVED BY ])ATE PERMIT NO. <br /> ..EH11241P£V. .. �' <br /> I £H 14-20 �/ {/ <br />