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APPLICATION FOR PERMIT <br /> SAN JOAQUi" LOCAL H=ALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. — <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 well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address - d Subdivision Name (OdY <br /> Owner's NameAddress Phone . <br /> Contractor's me License No. a 'r Phone �C <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 /> J Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation <br /> Eii8 mestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public Other Delta Type of Casing <br /> Irrigation Approx. Eastern <br /> Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> Type of Grout <br /> U Other <br /> (� Surface Seal Installed by OQ <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction IJ Well Diameter (p Ir Sealing Material (top 50') R <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 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 p� <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal l� <br /> SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Line lV, <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest; Well Foundation Property Line <br /> SEEPAGE PITS Cj 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 workmant 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 /> Theappli ant must c 1 f 11 fired inspections. Complete drawing on reverse side. _ <br /> Signed X Title: Date: J` <br /> —1,f� F DEPARTMENT USE ONLY <br /> Application Accepted by 1 f—L I _ _ Area ! ❑ Stk 466-6781 <br /> Additional Comments: EL di 369-3621 <br /> Pit or Grout Inspection by Date �� Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies V Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> rF <br /> EE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> NFO E14— +f <br /> s 3 I <br /> EH 13-24 REV. 10/82 G 10/82 500 <br /> 14-26 <br />