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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466--6781 <br />PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />PERMIT NO.W <br />DATE ISSUED <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 f-- well/pump <br />and the Rules and ReguIati of the San Joaquin Loc alth District.. Ailore <br />Job Address__51y�[�t��/%g�� Subdivision Name <br />Owner's Name 0 ACAddress Phone <br />Contractor's NarQ c icense No.�nS / Phone <br />TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION �� SYSTEM REPAIR OTHER <br />DISTANCE TO NEAREST: SEPTIC TANK] SEWER LINES DISPOSAL FLD, %Z)O PROP. LINE <br />FOUNORTION/ / AGRICULTURE WELL OTHER WELL �---�+ PITS/5UMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />II 1 Industrial U Open Bottom Manteca Dia. of Well Excavation <br />omestic/Private Gravel Pack Tracy Dia. of Well Casing <br />L] PublicOther Delta <br />Irrigation Type of Casing <br />Lj 9 Approx. ❑ Eastern <br />❑Specifications <br />Cathodic Protection <br />Depth17 <br />Depth of Grout Seal / <br />Geophysical Type of Grout ?c• "rsr l.iC (� <br />U Other l <br />Surface Seal Installed by �f2Q, �% �• lM-fi <br />Repair Work Done [-] Type of PumpH. P. f State Work Done <br />Well Destruction [J Well Diameter Sealing Material (top 50') _ <br />Depth Filler Material (Below 50') <br />TYPE OF SEPTIC WORK: NEW INSTALLATION [ REPAIR/,ADDITION 7] (No septic tank or seepage pit permitted if public sewer is <br />available within 200 feet.) <br />Installation will,serve: Residence _ Commercial <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet:, <br />SEPTIC TANK L Type/Mfg <br />PKG, TREATMENT PLT. ❑ Type/Mfg <br />SEWAGE SYSTEMDistance to nearest: Well <br />DESTRUCTION ❑ <br />Other <br />Lot size <br />Capacity <br />Capacity <br />Foundation <br />Water table depth <br />No. Compartments <br />Method of Disposal <br />Property Lire <br />LEACHING LINE <br />[ <br />No. & Length of lines <br />Total length/size <br />FILTER BED <br />Distance to nearest: Well <br />Foundation Property Line <br />SEEPAGE PITS <br />❑ <br />Depth Size <br />Number <br />SUMPS <br />[ <br />Distance to nearest: Well <br />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 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 />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 iss , I shall employ persons subject to workman's compensation laws of Ca�fornia." <br />The applicant cal�,Fll equire i spectionS. omplete drawing on reverse side. <br />Signed X Title: Date: <br />PARTMENT USE ONLY Area /7 �L Stk 466-67$1 <br />Application Accepted by [HC/„�/ , <br />Additional Comments: Lodi 369-3621 <br />Pit orrout nspection by Date �r�% �Z [ Manteca 823-7104 <br />Final Inspection by <br />Date /Z /� L Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br />FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br />INFO � 00 .p�Gl G <br />-4 -2— llG)i <br />EH 13-24 REV. 10/8214-26 (0 n <br />500 <br />