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APPLICATION FOR PERMIT <br /> SAN JCAQUIN LOCAL HEALTH DISTRICT <br /> '1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephore (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 6 <br /> (Complete in Triplicate) <br /> a <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 Local Health District.. <br /> Job Address q 4L _00 <br /> �. in-fie <br /> Owner's Name <br /> " Address Phone �� <br /> Contractor's Name License No," Phone s <br /> TYPE OF WELL/PUMP WORK: NEW WELL [ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR L7 OTHER j� X0.4 •A t+.w 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ^j <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 a <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑Other ❑ Delta <br /> Ljirrigation Approx. ❑ Eastern Type of Casing <br /> Cathodic Protection Depth Specifications <br /> ❑Geophysical <br /> Depth of Grout Seal <br /> ❑Other Type of Grout <br /> Surface Seal Installed by <br /> RM"+P Work Done Type of Pump 1— H.P. State Work Done ` <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501) ��N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [j (No septic tank or seepage pit 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 Lot size <br /> Character of soil to a depth of 3 feet: Water table depth lL� " <br /> ' <br /> 1. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line j <br /> DESTRUCTION ❑ " <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS U 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." 1 <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 f all required inspections. Complete dr wing on reverse side. <br /> Signed X �.. Title: , Date: <br /> OR DEPARTMENT <br /> Application Accepted by Area 5tk 465-6781 <br /> Additional Comment j] Lodi 369-3621 <br /> Pit or Grout Ins on by Date Manteca 823-7104 i <br /> Final Inspection by Date l� Z fir& L Tracy 835-6385 <br /> Applicant - Return all copies 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, j <br /> INFO ! <br /> EH 13-24 REV. 10/8210182 <br /> 4(0-0 <br /> j (� lO/82 500 <br /> 14-2b L}1- <br />