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,.r <br />APPLICATION FOR PERMIT <br />+ SAN JOAQUiN LOCAL HEALTy DISTRICT- <br />,T <br />-1601 E- HA.ZELTON AVE;, STOCKTON, CA PERMIT NO. <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1,YEAR FROM DATE ISSUED < DATE ISSUED_ <br />(Complete in Triplicate) <br />Application <br />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 o th San `oaou• oc H alth District. <br />Jab Address Subdivision Na e <br />)) <br />Owner's Nam Address �1/ll+ Phone <br />' <br />Contractor's Na '� <br />License Na. - Phone. <br />TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />€ PUMP INSTALLATION SYSTEM REPAIR OTHER U r <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL 0 ER -WELL PITS/SUMPS <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 Tracy Dia.'of Well Casing <br />Public CJ Other Delta <br />Type of Casing <br />Lj Lrrigation Approx. Q Eastern <br />Specifications <br />Cathodic Protection Depth S P <br />Depth of Grout Seal <br />Geophysical <br />U Other Type of Grout <br />Surface Seal Installed by <br />Repair Work Done ❑ Type of Pump H.P, State Work Done <br />Well Des,`fruction U Well Diameter ;Sea.Ttng Maierial (top 50') � <br />04) <br />DepthF-i3-1:er.Ma'ter-ial' (Below 50' ) <br />TYPE OF-SERThC WORK- NEW`[NSTAELATION`ftI REPAI ADDITION 1 �(No septic tank o seepage pit <br />peYritted if public sewer is <br />z available within 200 feet.) <br />Installation will serve: Residence._Cormmer`cial Others <br />_ <br />Number of livingunits: Number of bedroom \ / <br />�.- , Lot size <br />Character of soil to a depth of 3 feet; i. -' Water table depth <br />SEPTIC•.TANK Type/Mfg <br />- U Capacity. No. Compartments <br />7 KG, TREATMENT PLT. ❑ Type/Mfg .Capac-ity ` Method..of Disposal <br />�SEWR SYSTEM Distance: to neares.t.,__Weli_� - - .�.oundation-= Property Line <br />DE <br />DESTRUCTION ❑ - � - <br />LEACHING LINE No. & Length of lines =L Q Tbt.l )ength/size X <br />` <br />IL7ER BED Distance to nearest: Wel 1l Foundation Property Line <br />y <br />fSEEPRGE PITS Depth Size Q Number <br />_ __1?C'_1 <br />SUMPS' _}- Distance to nearest: Well Foundation 4 f Property Line_ _ <br />may, <br />DISPOSAL PONDS r s <br />Intl <br />�._I hereby certify that I have prepared this applicationand that-��the work will beadone in accordance with San Joaquin county <br />i <br />,,ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />-1 <br />Home -owner Tr icensed agent''_rsTgnature certifies the following: "I certify that in the performance of the work for which this <br />rpermit is issued;;vi shall .not. employ. any person in such manner as to become subject to workman compensation laws of California." <br />Co,`,ntraotor's hiriln'or "I <br />sub-contracting'si,griature•certifies the following: certify that in the performance of the work for which <br />" this <br />.r/permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />The applicant st cal f r 11 required nspecrdo s, Complete dra117 reverse side. <br />�Si9ned'X Title: ' �_ Date <br />ONLY Y <br />s r Applic on Accepted by Area 5Lk 466-6781 <br />Additional Comments: �• t Dyr Lodi 369-3621 <br />Pit or Grout Inspection by Date A _ ' .Manteca 823-7104 <br />Final Inspection by :-� Date -+-- -' Tracy 835-63B5 <br />Applicant - Return all copies to: Env 61r—ental Health Permit/Services 1601 E. Hazelton rve., P.O. Box 2004, Stk., CA 95201 <br />FEE <br />BASE <br />AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br />INFO <br />Li S, <br />EH -612,4 REV. 10/82 10/B2 500 <br />14.-26 <br />