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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> " <br /> PERMIT EXPIR9S,1.YEAR FROM DATE.ISSUED,: <br /> .ec (Complete in Triplicate?'. ":w:kit t,Ijlk <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein'des6ri bad. This application is <br /> made in compliance with San,Joaquin Count0rdinance No;549 forsewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. S, <br /> -7�L <br /> L <br /> 'L Si PM <br /> Job Address .30 Ci� Lot 7e <br /> Owner's s ameAddress Phone <br /> Contractor's Name License No. 2" Phone i!�6�- e to <br /> D <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ID DESTRUCTION 0 <br /> PUMP <br /> INSTALLATION-El SYSTEM REPAIR 0 OTHER C l' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t- El Industrial C1 Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1-1 Domestic/Private Ll Gravel Pack- El Tracy Type of Casing Specifications ll <br /> • Public El Other 171 Delta Depth of Grout Seal Type of Grout <br /> • Irrigation ---Approx. Depth El Ea stern Surface Seal Installed by <br /> Repair Work Done 0 1 Type of:Pump H.P. State Work Done <br /> Well Destruction 0 W411 Dialmeter Sealing Material (top 501 <br /> Depth Filler.Material-I Below-501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION El DESTRUCTION E-(No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation Will serve: 'Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. El Method of Disposal <br /> I <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines length/size <br /> FILTER BED F1 Distance to nearest: Well Foundation Property Line <br /> —4 <br /> I <br /> SEEPAGE PITS 0 Depth Size Number <br /> SUMPS I0 Distance to nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that./ hw)e prepared this application and that the work will be done in accordance With San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District.. I <br /> Home owner or licensed agent's signature certifies the following: ','I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Califomia." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." I <br /> The applica st call for all required pmmete <br /> inspeyqC I drawing on rev <br /> ona,_ -1 <br /> 1 .17 <br /> Signed if Title: Date: 7 -Z <br /> F6 EPARTMiENT USE ONLY <br /> Application Accepted by' Date <br /> Pit or Grout Inspection by ate Final Inspection by Date <br /> Additional' Comments: Wo cad. -For - 9A,11409LJ. t,,'/U <br /> 0 Stk 466-6781 + 0 Lodi 369-3621 y 0 Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant- Return all copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> 'INFO, CK' AMOUNT DUE MOUNT REMITTED CASH RECEIVED BY DATE PERMIT';NO.' <br /> + EH 13-24(REV. <br /> 10/83) -7- 5 <br /> EH 14-2B <br />