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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �Qz rj <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> �j <br /> PERMIT EXPIRES 1 YEAR FROM DATE 155UE0 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 an Joaquin Local He lth District. <br /> Job Address Subdivision Name <br /> Owner's Name <1 Address _ — .�p� —�� Phone <br /> 099 pop <br /> Contractor's Name_ _ _ License No. q Phone <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 FLO. 1 � ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ne <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial (J Open Bottom n Manteca Dia, of Well Excavation <br /> 7a'Domestic/Private F-1 Gravel Pack ❑ Tracy Dia. of Well Casing <br /> L7 Public EI Other L] Del to <br /> Type of Casing <br /> Ljlrrigation Approx. Eastern Specifications <br /> 7 Cathodic Protection Depth <br /> Depth of Grout Seal <br /> EJ Geophysical <br /> Type of Grout <br /> U Other <br /> Surface Seal Installed by <br /> Repair Work Done F] Type of Pump. �_Y��State <br /> H.P. Work Done <br /> Well DestructionE] Well Diameter ryJ4 Sealing Material (top 50') 0," <br /> Depth AIS` Filler Material (Below 50') <br /> EPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION U (No septic tank or.seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wi ve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 fe Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg a acity 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/siz <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS 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 workmanIs 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 iss , I s all employ persons subject to workman's compensation laws of California." <br /> The applicant ly4 call N all re ' ed i sped Complete drawing on reverse side. <br /> Signed X - Title: r5 Date: ^' <br /> OART E T USE ONLY <br /> Application Accepted by 16P Area v E Stk 466-6781 <br /> Additional Comments: fes— Lodi 369-3621 <br /> Pit or Grout Inspection Date Manteca 823-7104 <br /> by <br /> Final Inspection by L 4 Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 160 E. H zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> rINFO <br /> EE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> $3 '93-S" . <br /> EH 13-24 REV. 10/82 �7 n 10/82 500 <br /> J4-26 <br />