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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <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 thei:San Joaquin Local Health District for a permit to construct and/or install the work herein F <br /> described. This application is made in compiia ce with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump ` <br /> and the Rules and Regul ns /the S n Jo Local' Health District. <br /> Job Address ( f+d division Name <br /> Owner's Name Address <br /> �PhonContractor's Name License No. (. <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER LJ <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f ,i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack E] Tracy Dia. of Well Casing nfl <br /> Public G Other ❑ Delta Type of Casing V <br /> i V Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth L A <br /> ❑ Ptv, Depth of Grout Seal � <br /> Geophysical "— ""` Type of Grout <br /> U OtherSurface Seal Installed by <br /> Repair Work Done FJ Type of Pump H.P. o+—w* State Work Done <br /> Well Destruction ❑ Well Diameter - Sealing Material (top 50') — <br /> Depth Filler Material (Below 50') <br /> L <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPA-I-R/ADDIT-ION-HJ—•(No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other. . 3 <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> k SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> I PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal <br /> I SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br />` LEACHING LINE U No. &:Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well FoundationProperty. Line,_ <br /> SEEPAGE PITS ❑ . Depth Size Number - Y <br /> SUMPS Distance to nearest Well-' - Foundation Property Line <br /> DISPOSAL PONDS CI <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 /> F permit is issued, I shall not employ any person in such manner as to become subject to workmant 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 is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applica st call r aloqu' n ec ions. Complete dr ing ongtvr <br /> e C3>> <br /> Signed X Title: Date: <br />} FOR ART T USE ONLY <br /> --fir-ea Stk 4fi6-6781 <br /> Application Accepted by <br /> ' Additional Comments: Lodi 369-3621 <br /> G Pit or Grout Inspection Date MM nteca 823-1144 <br /> Final Inspection by Date L Bracy 835-6385 <br /> Applicant - Return all copies to: Environmental Hea-lth Permit/Services 1601 E. HazeltAve., P.O. Box 2009,, Stk., CA 95201 <br /> on <br /> FEE BASE AMOUNT DUE RMOUNT REMITTED RECEIVED BY DATE PERMI jNO. <br /> INFO <br /> S, o ILA-a14 �. <br /> 10/B,5000 `.. <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />