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APPLICATION FOR PERMIT �MS141 <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT PP► tvD <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES'l YEAR FROM DATE ISSUED <br /> t. (Complete in Triplicate) : ry�NvlR06r�I �rlCES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he(�E his application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1.862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. jqs <br /> Job Address <br /> City Lot Size PM <br /> Address Phon <br /> Tr5S 2., <br /> Owner's Name t. r <br /> Contractor <br /> Address - 7� License No. Phone�� �/ <br /> TYPE OF WELL/PUMP: '.A!�� EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ;roo'-' ' SYSTEM REPAIR ❑' OTHER, ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK,,'_ SEWER LINES DISPOSAL FLD- PROP. LINE V 1� <br /> FOUNDATION ' AGRICULTURE WELL OTHER WELt PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> h lustrial [I Open Bottom 1-1MantecaDia. of Well Excavation Dia. f Well Casing <br /> Cl I <br /> Domestic/Private C1 Gravel Pack (racy Type of Casing Specifications <br /> ❑ Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout <br /> {] Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> t Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nosbpeiwisyth te20permitted <br /> f Bitted if public sewer is <br /> avar <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth--j <br /> SEPTIC TANK 0 Type/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. ❑ '3: Method of Disposal <br /> i Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED [I Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 appli must call r all required inspections. Complete drawing on reverse side. <br /> Title: Date: <br /> Signed <br /> FOR EPART ENT USE ONLY c <br /> .. Date —L'7 �a 7 Area <br /> Application Accepted by <br /> 2 Y7 <br /> Pit or Grout inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83543385 <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 ASH RECEIVED BY DATE PERMIT'NO. <br /> INFO (/^ <br /> + EH 13-241REV. /as7 �,� �- <br /> EK 14.26 <br />