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APPLICATION FOR PERMIT <br /> (� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. (J`Q 3—//i 1q3 <br /> Telephone (209) 466-6781 DATE ISSUED <br /> �Pl�\V_(C,.plete <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 14 ; <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for NZV <br /> and the Rules and Regulations f t;e San oaq in Local Health District.Job Address Q Subdivision NameOwner's Nam.ZW- Address Phone <br /> Contractor's Name +� C License No. 7�� 3 Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F-] DESTRUCTION ❑ ) <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <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 /> J Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> mestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public Other Delta <br /> Type of Casing <br /> IrrigationO Approx. []Eastern �� <br /> Depth Specifications (� <br /> ❑Cathodic Protection Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> LJ Other <br /> Surface Seal Installed by yj/f� t�pj ToLL. <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U 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 <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <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 <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line P- <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <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 is2ca <br /> shall emplo erso subjec to workman's compensation laws of California." <br /> The a ant mustfor all r red specti s. Complete drawing on reverse side. <br /> Signed X' Title: . Date:! s <br /> RTME E ONLY <br /> �d�itional <br /> n Accepted y Area �— Stk 466-6781 <br /> Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date e-Ar-0 ❑ Manteca 823-7104 <br /> Final Inspection by I Date ❑ 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. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />