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APPLICATlON..FOR PERMIT <br /> SAN JOAQUIN'LOCAIL`HEALTH DISTRICT- <br /> 16.01 E. HAZELTON'AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ; <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete'in Triplicate)'!,- ._ <br /> Application is hereby made to the San Joagtdrt Local Health District for a permit to construct and/or Install the work herein described TMs aw.lcailon;ls <br /> made In oomplianoa wkti San JoaquIdti0unty.Oidiriaisd6 No-:'549 for sewage or No:1862 for welt/pump'end the Ames and Rdoulatior*..of the'San Joaquin <br /> Local Health <br /> i�' iJob Address 'Lot <br /> Lot Size <br /> Owner's Name Address G �� ,> ; r� Phone <br /> Contractor's Name Aupoear License No. Phone. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION}, . <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE, <br /> — <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom,:`__. ?❑ Manteca Dia.`of.Well Excavation Die. of Well Casing -' <br /> ❑ Domestic/Private ❑ Gravel Pack- ❑ Tracy Type of Casing Specifications. <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Sea! Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal.lnstalled by i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> i <br /> Well Destruction �¢ Depth er Material (Below 50')Well Diameter �Sealing Material (top 50'i <br /> /' J.,.< <br /> ""' Fill <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION ❑ DESTRUCTION 13 (No septic system permitted if public.aewer is.. __, <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Numbei of Irving units: Number of bedrooms <br /> Character of soil to a depth of 3'feet Waterlable depth <br /> .SEPTIC.TANK ❑ Type/Mfg Capacity ..'No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r <br /> Distance to nearest, Well Foundation - Property Line _ � - �• - _ <br /> LEACHING LINE ❑ No. &length of linea Total length/size <br /> FILTER BED ❑ 'Distance to nearest: Well Foundation Property Line <br /> a - <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line l <br /> DISPOSAL PONDS ❑ <br /> I <br /> I hereby certify that 1 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. i <br /> Horne owner or licensed agent's 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." 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 compense- <br /> tion laws of California.*' <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. <br /> Signed X opi Title: A3b a Data,• r <br /> .1 <br /> FOR DEPARTMENT USE ONLY, <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> p <br /> Additional Comments: ! <br /> ❑ Stk 486-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 • ❑ Tracy 835-8385 <br /> Applicant- Return all copies to: F-rMronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,,CA 96201 I ' <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE' PERMiT'NO. <br /> INFO j <br /> EN 13 it 411EY.11018M s y - 1 <br /> " ", _ "r -• F T. aY``7 t r , i •'% ti- a f c. '� l.l,:: ��,k' �-...N <br />