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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_) 46676781 <br /> PERMIT EXPIRES1 YEAR FROM DATE ISSUED 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 0Rega ns of the San J aqu' Lp1 He�,7tb District. <br /> Job Address [[�� JJ f�Subdivision Name <br /> Owner's Name Q Address. Phone <br /> Contractor's Name ' <br /> rY License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT Wf DESTRUCTION � <br /> PUMP INSTALLATI0�1 (] SYSTEM REPAIR- OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 09 DISPOSAL FLD. PROP. LINE_ <br /> FOUNDATION fMi7+Z- AGRICULTURE WELL OTHER WELL PITS/SUMPS •�� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �3 <br /> I� Industrial Open Bottom <br /> ❑ P ❑Manteca Dia. of Well Excavation <br /> Zfi Domestic/Private ❑Gravel Pack (� Tracy Dia. of Well Casing <br /> Public + �j Other (� Del to <br /> LApprox. EJEastern <br /> _j Irrigation Type of Casing <br /> Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> Other. .Type of Grout / <br /> Surface Seal Installed by <br /> Repair Work 6ne EJ Type of Pump H.p. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION [j-' (No septic tank or seen <br /> page pit permitted if public sewer is <br /> it <br /> Installation will serve; Residence I available within 200 feet.) �_ <br /> _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size rC>d' <br /> Character of soil to a depth of 3 feet: t Water table depth v Irl <br /> SEPTIC TANK 0 Type/Mfg ( Capacity No. Compartments <br /> PKG, TREATMENT PLT. Type/Mfg <br /> Capacity Method of Disposal <br /> Distance to nearest; Well Foundation Property Line <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BfDDistance to nearest: Well Foundation f Property Line ' <br /> SEEPAGE PITS ❑ Depth Size <br /> +,.Number <br /> —TSUMPS ❑ Distance to nearest: Well Foundation i Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the wort/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 f+ <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman t 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, shall employ persons subject to workman's compensation laws of California." <br /> The applicant s all for a required inspections'>Compleette drawing on reverse side. <br /> Signed X Title: '°�, f <br /> Date: <br /> FO EP ENT USE ONLY � <br /> Application Accepted by Are 0. Stk 466-6781 <br /> Come Additional Coents: 0. Lodi 369-3621 ` <br /> Pit o Grout Inspection by Dat g= -7- q Manteca 823-7104 <br /> Final Inspec on y T=•-! Date <br /> Tracy 835-6385 A <br /> Applicant 'Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,'CA 95201 <br /> FEE BASE NAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO' <br /> �- EH 13-24 REV. 10/82 „ 10/82 500 <br /> 14-26 t <br />