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i APPLICATION FOR PERMIT <br /> € ') SAN'JOAQU;N LOCAL HEALTH DISTRICT <br /> 1601 E. HA7ELTON AVE.,. STOCKTON, CA PERMIT N0, <br /> p one (209)-466-678I cJh <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> i <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 <br /> S ui-vaie+rivs me. �j <br /> Owner's Name (�(, Address <br /> Contractor's Name G Phone <br /> � !�� License.No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U Ud <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE$ DISPOSAL FLD. PROP, LINE <br /> f <br /> FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA . CONSTRUCTION SPECIFICATION'S <br /> Industrial ❑ Open BottomManteca ' <br /> ❑ Dia. of Well Excavation <br /> LI Domestic/Private [� Gravel PackTrac <br /> ❑ Public ❑ Y Dia. of Well Casing � <br /> Other ❑ Delta <br /> Irrigation Approx. Eastern Type of Casing <br /> ❑ Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal + <br /> LJ Other ' =-Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 9 (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: R s'dence 7ic Commercial Other available within 200 feet.) <br /> Number of living units: Number of bedrooms 2— Lot size Q <br /> Character of soil to a deuth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Ca acit <br /> Capacity No. Compartments <br /> PKC. TREATMENT PLT. ❑ Type/Mfg Capacity � � Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation <br /> DESTRUCTION ❑ Property Line <br /> LEACHING LINE No. & Length of lines Total length/size ---- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line C� <br /> SEEPAGE PITS Depth $ ze tNumber <br /> SUMPS Distanc�to neare l/ J 1 ® Foundation -�a' Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that ] have prepared th s application and that the work will be done in-accordance witY2. <br /> Joaquin county <br /> ordinances, state laws, and rules and r gulations of.the San Joaquin Local Health District. <br /> home owner or licensed agent's signatur certifies following: "I certify that in the performance ofwork for which this ` <br /> permit is issued, I shall not employ an ers such manner as to became 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 issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant s call for requited 7'pections. Complete drawing on reverse side. <br /> Signed. X ��// 't—'Title: NJ�i�► Date: <br /> FOR D;PARTME <br /> Application Accepted b ea kL <br /> tk466-6781 <br /> Additional Commeodi 369-3621 <br /> Pit or Grout Ins on' Date anteca 823-7104 <br /> Final Inspection by DateZ L7Tracy 835-6385 <br /> Applicant - Return all copies to: . Envir mental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE �3RMITEN0. <br /> INFO <br /> ND <br /> --t-� � -� G <br /> EH 14-26-24 REV. 10/82 US 10/82 500 <br /> w <br />