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5 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> ' 16,01't--F{A,ZE'�. ()NAVE; STOCKTON, CA <br /> Telephone (249) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> i <br /> (Complete in'Triplicate)' , <br /> ' Application is helehy made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> ' made in"compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of tlS uin <br /> Local <br /> Health District" <br /> /GC> t/ ✓ 1 y Ci Lot Size f PM <br /> Job Address l� r/ <br /> + ass <br /> Owner's Name ��� <br /> t' n License No/ Phvne <br /> Contractor Vi a.ddr ss <br /> TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ' PUMP INSTALLATI:QN ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ 1 <br /> DISTANCE TO NEAREST: SEPTICtTAIVIC`} 1 y SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> D industrial ❑ Open.Bottom .❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> w ❑ Do <br /> tic/Private ❑ Gravel Pack "" El Tracy <br /> Type of Casing Specifications <br /> { ublic c ❑ Other F1Delta Depth of Grout Seal Type of Grout <br /> _t <br /> I I"Irrigatian _Approx. Depth I i E tern Sufrface Seal Installed by <br /> l H.p. / State Work Done <br /> j Repair Work Done U8 Type of-Pump H.P. r <br /> r VWell Destruction ❑ Well Diameter Sealing Material (tap 50') .• <br /> Depth_ Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer.is <br /> available within 200 feet.) I <br /> Installation will serve: Residence* Co martial— Other <br /> 1 <br /> Number of living units_ Number_ot.bedrooms-��--;-. <br /> ti 1 a r Water table depth" ° <br /> Character of soil to a depth of 3 taut: r1 r , <br /> SEPTIC TANK ❑ Type/Mfg "Cepa ity 'ytt *" No. Compartments'' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation �"" Pioperty'Linery —" t✓' <br /> LEACHING LINE ❑ No. &r Length of lines Total lengt�lsi� <br /> _I <br /> FILTER BED EI Distance to nearest: Weil Foundation t /Property Lie fi _ <br /> SEEPAGE PITS l I Depths Size Number i <br /> rg <br /> SUMPS ❑ Distance to nearest: Well Foundation '• Property Line ° <br /> DISPOSAL PONDS 171, 14' "!y i <br /> i <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 regulationsJortify that in the p <br /> aquin Local Health District. , <br /> Home owner or li sed agent's s nature certifies the following: "I ceerformance of the work for which this permit is issued,`i shall not <br /> employ any per n in such manner as to become subject to workman's compensation laws of California."_ Contractor's hiring or sub contracting signature <br /> certifies the f owing: "I certify t the perform e f the w for which this p s issued, I shall employ persons subject to workman's co ansa <br /> tion laws of alifornia" <br /> The applic t mus r all squired s drawin on r arse e• <br /> e: ate: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by . <br /> Data <br /> Area <br /> Pit or Grout Inspection by Data Final Inspection by a Date <br /> Additional Comments: <br /> D.Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> { r� <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVECK 9D BY PATE PERMIT Nd. <br /> INFO <br /> - _ <br /> � <br /> r EH 13.24(REV.t H M 436 . <br /> - _ EH 14-M <br />