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APPLICATION FOR PERMIT <br /> SAN JOAQJIN LOCAL HEALTH DISTRICT C <br /> 1601 E. HAZELTDN AVE., STOCKTON, CA PERMIT NO. I J <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 San Joaquin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name Address Phone3� �� <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL rg WELL REPLACEMENT DESTRUCTION rt <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK 100 ,A- SEWER LINES DISPOSAL FLD, iUIJ PROP. LINE f=7` vLI <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> I J Industrial [_1Open Bottom [ Manteca Dia. of Well Excavation J <br /> Domestic/Private Gravel Pack t&Tracy Dia, of Well Casing <br /> Public F-1 Other ❑ Delta Type of Casing [ .fe�— 11..o <br /> LJ Irrigation Approx. Eastern <br /> Depth � Specifications <br /> Cathodic Protection Depth of Grout Seal <br /> 1-1 Geophys i ca l <br /> Type of Grout <br /> Other Surface Seal Installed byf <br /> Repair Work Done G Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (tap 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other 1 (� <br /> Number of living units: Number of bedrooms Lot size <br /> V 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> 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 Property Line <br /> DESTRUCTION <br /> LEACHING LINE LI 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 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 <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 fallowing: "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 Is compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit isissu d, I shall employ persons subject to workman's compensation laws of California." <br /> The applican t all f ' <br /> all 'required inspections. Complete dr ng on verse sid11 <br /> Signed X Title: Date: <br /> PARTMENT USE ONLY <br /> Application Accepted by Area [—] 5tk 466-6781 <br /> Lodi 369-3621 <br /> Additional Comments: <br /> Pit or Grout Inspection by Date �'^ Manteca 823-7104 <br /> Final Inspection by Date ❑ 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 /> FEEBASE AMOUNT. DUE AMOUNT REMITTED RECEIVED BY f j OpA�TE PERMIT NO, <br /> INFO -1�-?3 � <br /> EH 13-24 REV. 10/82 1+0/82 500 <br /> 14-26 <br />