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APPLICATION. FOR,PERMiT ; <br /> jSAN JOAQU;N LOCAL HEALTH DISTRICT <br /> ' 1601 F. HA7ELT0N AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 x <br /> ' U] DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. <br /> �[y (Complete in Triplicate) <br /> - <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1862 for well/pump <br /> and the Rules and Regulations of the Sa Jodquin Local Health District. <br /> Job Address Subdivision Name <br /> i Owner's Name p pI Address S, Phone <br /> Contractor's Name <br /> O t,A/ License No, Phone � <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U ) <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSQ��7 <br /> J Industrial U Open Bottom Manteca Dia, of Well Excavation <br /> U Domestic/Private ❑Gravel Pack Tracy Dia, of Well Casing <br /> Public F-1 0ther Delta <br /> � Type of Casing <br /> t V Irrigation Approx. ❑ Eastern Specifications <br /> Cathodic Protection 'Depth <br /> Depth of Grout Seal <br /> Geophysical <br /> Other Type of Grout <br /> U <br /> Surface Seal Installed by <br /> Repair Work Done FJ Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE. OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> .Installation will serve: Residence _ Commercial _ Other , <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> i SEPTIC TANK Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation P Line <br /> DESTRUCTION � perty, , <br /> LEACHING LINE a No. & Length of lines ' - - Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> r <br /> DISPOSAL PONDS C <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and 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 <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." <br /> a, Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />' The applica st cal r Pl re aired inspections. Complete drawing on reverse side. <br /> Signed X �./ Title: Date: <br /> :GR�D�VPARTMENT U <br /> Application Accepted by Area _ Q Stk 466-6761 <br /> k. Additional Comments: Lodi 369-3621 <br /> Pit or Grout InspeodWr, by Date Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return.all copi to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. ,Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> to-3 o <br /> EH 13-24 REV, 10/82 1 10/82 500 <br /> 14-26 I <br />