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APPLICATION FOR PERMIT <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 <br /> Telephone (209) 466-6781 /f <br />{ GATE ISSUED <br /> PERMIT EXPIRES 1.YEAR,-FROM DATE ,ISSUED <br /> f t- <br /> (Complete in Triplicate) <br /> i 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 /> Job Address Subdivision Name <br /> Owner's Name Address 'SiamPhone <br /> Contractor's Name S License No. Phone ' <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ;K <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /A"' - DISPOSAL FLO. PROP. LINE <br /> )*\FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE + TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom F_j Manteca Dia, of WellExcavation <br /> u <br /> Domestic/Private J_]Gravel Pack Tracy Dia. of Wren Casing <br /> FI Public F-1 Other Delta Type of Casing <br /> Li Irrigation Approx. Eastern Specifications <br /> ❑ <br /> Cathodic Protection Depth Depth of-Grout Seal <br /> Geophysical �.^ Type of Grout i('1 <br /> Other v <br /> LJ � Surface Seal Installed by <br /> Repair Work Done F-1 Type of Pump H.P. ' State Work Done <br /> Well Destruction �Well-Diameter Sealing Material (top 50') _ <br /> ' Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW'•INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pA permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other <br /> E Number of living units: Number of bedrooms Lot size <br /> I Character of soil to a depth of 3 feet: Water table depth <br /> t SEPTIC TANK ; Type/Mfg Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of~Disposal <br /> SEWAGE SYSTEM a Distance to nearest: Well Foundation Property Line <br /> I DESTRUCTION <br /> LERCHING CINE U ".No. & Length of lines Total length/size <br /> i <br /> FILTER BED Distance to nearest: Well Foundation Property Line ' <br /> SEEPAGE PITS F7 " Depth Size Number <br /> 1 SUMPS �I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i { + <br /> [ 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 a5 to become s_uhject to workman compensation laws of Californiac <br /> f the work for which <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance o <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California. ' <br /> r. r <br /> The applicant must call for all re wired inspections. Complete drawing_ n reverse side. + <br /> Signed X Title: ��j,'�'y��'y� Date: �y <br /> " F DEP TMENT USE ONLY 4 Stk 466-6781- <br /> Application Accepted by Area <br /> Additional Comments: Lodi 621 <br /> r Pit or Grout Inspection by Date . LJ Manteca 823-7104 <br /> Final Inspection by ; Dat �_Qy❑ Tracy 835-6385 r <br /> Applicant - Return all cop to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FINFO <br /> FBASE 'AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERYTN <br /> rl <br /> i10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br /> J <br />