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4 � APPLICATION FOR-PERMIT <br /> PP �� SAN JOAQUIN LOCALNHEALTH DISTRICT' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781. <br /> PERMIT EXPIRES 1 YEAR"FROM DATE ISSUED 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 well/pump <br /> ar*C R l o R AZes of the San Joaquin Local .Health District, <br /> Job ddress <br /> Dwner s Name / j` _ Address" Phone <br /> Contractor's Name 4 _ cense No. t'F r Phone , ' l <br /> f <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <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 /> 17 IndustrialQ Open Bottom []Manteca�„ , Dia. of Well Excavation <br /> lamestic/Private F ravel Pack racy"_ ; "Ola: of Well Casing <br /> Publicv <br /> El Other Delta -�._.T - <br /> LI <br /> Irrigation / Type of Casing <br /> Approx. EJ Eastern Specifications <br /> Cathodic Protection Depth p <br /> Geophysical kDepth of Grout Seal ' <br /> L Other ^-Type of Grout ' <br /> / Surface Seal Installed by <br /> Repair Work:Done EJ' Type of Pump �? N,.P. 'State Work Done- <br /> Wel I <br /> one-Well Destruction U Well Diameter Sealing Material (top 50') U <br /> Depth Filler Material (Below 501) `. <br /> TYPE OF SEPTIC,WORK: NEW INSTALLATION U REPAIR/ADDITIOiV_1J N se tic tank or see �4 w- r I <br /> z P seepage permitted ifTpubTiic,sewer is"�'b -___J <br /> Installation will serve: Residence _ Commercial _; Dthe T available within 200 feet.) <br /> Number of living units: Numberof bedrooms Lot size <br /> Character of soilbto. a depth of 3 feet: Water table depth <br /> SEPTIC TANK Q Type/Mfg 1 "Capacity No. Compartments s <br /> PKG. TREATMENT PLT. 0 Type/Mfg I Capacity Method of Disposal <br /> Distance to nearest: Well Foundation property Line <br /> LEACHING LINENo; & Len oh of lines I <br /> ❑ g , Total length/size <br /> FILTER BED EJ Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Humber <br /> SUMPS 1J Distance to nearest: Well Foundation Property Line r <br /> DISPOSAL PONDS <br /> s <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 agents signature certifies'the".following: "!',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." r <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 shV 1 employ persons subject to workman's compensation laws of.California." <br /> The applicant muA cal fo all re fired inspections. Complete drawing on re rse side. <br /> Signed X <br /> Title: Date: <br /> F RT NT USE ONLY n <br /> Application Accepted by Area (;" _ 0 ^Stk 466-6?8'11 <br /> Additional Comments: F-1 Lodi 369-3621 <br /> Pit or Grout Inspection by Date MantecaQ 823-7104 <br /> Final_ Inspection by Date [a Tacy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEBASE AMOUNT DUE <br /> INFO : AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> 3` as -9 2'7 r <br /> EH 13-24 REV. 10%82 <br /> 14-26 10/82 500 <br />