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APPLICATION FOR ?ERMIT <br /> SP.N JOAQbi`� LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <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 <br /> Local Health District. <br /> Job Address At/ A Subdivision Name <br /> Owner's Name Address j ( �/� y fP Phone <br /> Contractor's Name 4 License No. .' Phone -- <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER'WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> 71 Domestic/Private v � Grayel_Pack` [J Tracy„ Dia. of Well Casing <br /> L7 Public Other Delta Type of Casing <br /> ❑ Irrigation Approx: F�] Eastern Specifications <br /> Cathodic Protection Depth <br /> ❑ ChdiPttDepth of Grout Seal- . <br /> 1-1 Geophysical Type of Grout <br /> LJ Other r Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump - H.P. State.Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> l IJ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION )< (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other f 6 <br /> Number of living units: Number of bedrooms Lot size x /,1 X Z q r <br /> 30 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK E1 Type/Mfg a Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Ei Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION] <br /> LEACHING LINE No. & Length of lines 3el Total length/size <br /> FILTER BED Distance to nearest: Well A Foundation � Property Line <br /> v <br /> SEEPAGE PITS ❑ Depth --XSi7e e Number <br /> �x <br /> I <br /> SUMPS Distance to nearest: Well 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�st 11 for all required inspe ions. Complete drawing on r a rse si . ` J� <br /> Signed X Ti le: ' Date: <br /> ENT NLY <br /> Application Accepte by Area Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Manteca 823-7104 <br /> Pit or Grout Inspection b Date <br /> Final Inspection b Date p2�S� ❑ Tracy 835-6385 <br /> Applicant - Return all c s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO I <br /> _F 4—I Lits I <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />