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APPLICATION FOR PERMIT <br /> r� SAN JOAQUiN LOCAL HE�,,LTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CAPERh1IT N0. — Q 0 <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 wel3/pump <br /> and the Rules and Regulations of the San Joaquin Local Health.District. <br /> Job Address 6�[� Subdivision Name <br /> Owner's Namewoo ` Address Phone <br /> Contractor's Name Licerse No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR 0_ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE �( <br />€ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O <br />` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d <br /> J Industrial U Open+Bottom Manteca Dia. of Well Excavation <br /> LJ Domestic/Private ❑ Gravel Pack L Tracy Dia. of Well Casing <br /> ?17, Public Otheir ❑ Delta <br /> Type of Casing <br /> Lj.Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth Depth of Grout Seal <br /> 17 Geophysical <br /> U Other Type of Grout <br /> t Surface Seal Installed by <br /> Repair Work Done ,Type of Pump H.P. State Work-Done <br /> - w- <br /> Well Destruction U .Well Diameter Sealing Material (top 50') _ <br /> ' Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIION RE ITION (No septic tank or seepage pit permitted if public sewer is <br /> LJ <br /> available within 200 feet.) <br /> Installation will serve: Residence _ CommercialOther <br /> Number of living units:- . K Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: �s _Q __ Water table depth d <br /> SEPTIC TANK LJ Type/Mfg. 3Capacity — No. Compartments <br /> PKG, TREATMENT PLT: 'Type /Mfgi,'3 .� � Capacity Method of Disposal <br /> SEWAGE SYSTEM - Distance to'ynearest:- Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Distance}to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth +L Size Number 1-3 <br /> SUMPS J Distanceito nearest: Well2_p 6 .�. Foundation 112 p(7-Property Line t i <br /> DISPOSAL PONDS ❑ _- >" — 1 <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. i <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 werkman§ 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-must call for S34 required inspections. Complete drawing 9p, reverse side. <br /> Signed X e Title: Date: 7-�/— 3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Area ❑ Stk 466-6781 <br /> Additional Comments: X Lodi 369-3621 <br /> Pit or Grout Inspection Date El Manteca 823-7104 <br /> Final Inspection by Date L7 Tracy 835-6385 <br /> Applicant - Return all copi Z to: Envi o mental 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 <br /> 5� () <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 t <br />