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-� APPLICATION FOR PERMIT , - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA rooiQF It <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NDkB', <br /> (Complete in Triplicate) '^ <br /> scribe <br /> .This <br /> r cation is <br /> Application is hereby made to the San Joaquin oc Local <br /> No.549 for sewage or it t 1 86onstrufont and ump atnd the Rules and Regulatioall the work herein de ns.of the Sas nJoaquin � • <br /> made m compliance with San Joaquin County <br /> Local Health District. <br /> City Lot Size <br /> Job Address <br /> Owner's Name <br /> �- Address Phone <br /> Contractor <br /> Address License No._.__�--Phone <br /> f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ©_' � <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER O <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '_AGRICULTURE WELL OTHER WELL PITS <br /> } FOUNDATION G <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC( pia. of Well Casing <br /> El industrial C3Open Bottom ❑ Manteca Dia. of ovation Specifications <br /> © Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing I <br /> .' Type of Grout <br /> F] Public Cl Other to Depth of Grout Seal r <br /> k <br /> I ! irrigation �_Appr pth: i I Eastern Surface Seal Installed by <br /> G <br /> H,P..- — - - - - �' State Work Done _ r� <br /> Repair Work Done ❑ of PumpCP <br /> Well Destructio Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION {.l REPAIRIADDITION l_I DESTRUCTION (No septic systemithin ranted if public sewer is <br /> avak <br /> Installation will serve: Residence_ Commercial— Other' <br /> r Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity n - _�_ _. , <br /> k rr -,.Method of Disposal <br /> PKG. TREATMENT PLT. ❑ J � <br /> Distance to nearest: Well Foundation Property Line <br /> t. <br /> LEACHING LINE ❑ No. & Length of lines_ "' a Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> I SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑" <br /> I 1 hereby certify that I have prepared this 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, V shall not <br /> employ any person in such manner as to became subject to workman's compensation laws of California.,,Contractor's hiring or subcontracting signature <br /> certifies the following: 111 certify that in the performance of the work for which this permit is issued,Y shall employ persons subject to workman's compensa <br /> tion laws of Califo <br /> i The applicant to or a ins io s. Complete drawing on reverse side. <br /> Title: Date: <br /> Signed X <br /> �OltEPARTMENT USE ONLY tt 17 <br /> Date -tom Area <br /> ' Application Accepted by <br /> I Date Final:InspectionPit or Grout Inspection by by Date <br /> Additional Comments:: "L� <br /> G. ❑ Stk 466-6781 ❑ Lodi 369-3621 Il Manteca -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 RECEIVED BY DATE jZPERMIT21n IVO. <br /> AMOUNT DUE AMOUNT REMITTED SH <br /> INFO <br /> S p� <br /> ! ♦ EH 13-241REV.1/851 <br /> F - EK 14-26 -- <br />