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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 <br /> GATE 1SSUE0 3/ J-i <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 /> Jab Address ivision Name <br /> Owner's Name 14 Address 44 Phone ~p f <br /> Contractor's Name � spy- y License No, Phone ��7 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION µ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> (DISTANCE TO NEAREST: SEPTIC TANK EWER Lr DISPOSAL DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I Industrial_.XGravel <br /> UJOOpenD-Manteca ,. . Dia.- of Well .ExcavationDomestic/Private Pack Tracy Dia. of Well Casing <br /> ublic jOther [ 6eIta S <br /> Type of Casing f <br /> F, irrigation _�0 Approx. EJ Eastern <br /> r 9 <br /> Cathodic Protection Depth Specifications Ica1 � <br /> L]Geophysical Depth of Grout Seal ^ <br /> U Other Type of Groutg&60 (}lh k <br /> Surface Seal Installed by 1�/t�[fjlalr <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') fi <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW 14STALLATION 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 s <br /> i <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth 6 <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments L <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 U No. & Length of lines - Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property tine <br /> SEEPAGE PITS Cj Depth Size Number <br /> " SUMPS Distance-to nearest: 'W6i1 -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 issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant call r al re ired inspectiors. Complete dral,a g on reverse side. <br /> Signed XTitle: Date: <br /> FOR A TEN ONLY <br /> Application Accepted by Area Q Stk 466-6781 <br /> Additional Comment s• Lodi 369-3621 <br /> Pit or Grout Inspe on by Date — Manteca 823-7104 <br /> Final Inspection by Date &;�-Iracy 835-6385 <br /> Applicant -,Return all copies to.: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> FEE I BASE AMOUNT DUE AMOUNT REMITTED RECE-IVSD BY DATE PERMIT NO. <br /> INFQ <br /> 3/Cy <br /> EH 13-24 REV. 10/82 10/82 50C <br /> 14226 <br />