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-ems- --^•�^"� �'"- .. h <br /> 4 <br /> APPLICATION FOR PERMIT f <br /> 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /orinstall theWOTk herein described.This <br /> cation is <br /> Application is compliance Sano the Joaqu n County Ordinance n Joaquin lHea Nto. 549 for sewage orh District for a +No. 1862 fort to GwelUpump and the Rules and R gulations of the Sanl Joaquin <br /> made in compl+an <br /> Local Health District. I <br /> City Lot size PM <br /> Job Address <br /> 1 <br /> Pho <br /> Address <br /> Owner's Na <br /> ilJ= «z License N . Phon <br /> Contracto Address, <br /> I+ TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ OTHER 171PUMP kNSTALLATION ❑ <br /> DISTANCE TO NEAREST: SEPTIC.TAiNK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of WelCasing❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wekl Excavation Type of Casing5pecificati❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Gr <br /> ❑ Public F1 Other F1 Delta Depth of Grout Seal <br /> I ! Urigation _.Appr�. Depth t 1 Eastern Surface Seal Installed by <br /> State Work Done <br /> Repair Work Done L3 Type of Pump <br /> H.P. <br /> aSealin '1 <br /> j We11 Destruction ❑ Well Diameter 9 Material (top 50 <br /> 1 Depth t Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTIO Ipseptic <br /> withinsystem <br /> 200 feet.] if public sewer is <br /> available + <br /> Installation will serve: Residence L Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK )410Type/Mfg ! ° Capacity_14a7Z? o. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT_.❑ � <br /> .. Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS ❑ 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 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 applicant must call fo all req red inspections. mplete drawing on reverse side. /� �� <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date 01 C 9'U Area <br /> Application Accepted by <br /> (7Pit or Grout Inspection by Date Final inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 01&q 3 S' <br /> nVEM!9&&K RE EIVED BY DATE PERMIT NO. <br /> SH 0♦ EH 13.241HEV.I h) ��' �" <br /> EH 14-26 11 <br />