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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTDN AVE., STOCKTON, CA C# <br /> Telephone (209) 466-6781 PERMIT N0. 11 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED a j <br /> (Complete,in Triplicate) <br /> Application is hereby made to thel <br /> described. This application is San Joaquin Local Health District for a permit to construct and/or install the work.herein <br /> Ian <br /> in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wel <br /> Ir and the Rules and Regulations of the San Joaquin Local Health District. 1/pump Job Address Z [ .I <br /> Subdivision Name 4L <br /> Owner's Name �, Address —a< <br /> Contractor's Name , T Phone (, <br /> S O License No. 021743 Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL1� ❑ DESTRUCTION ❑ <br /> WELL REPLACEMENT <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK / " SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ��— <br /> I <br /> 1--1Industrial - CONSTRUCTION SPECIFICATIONS <br /> U Open:Bottom ❑Manteca Dia, of Well Excavation <br /> � 'Oomestic/Private gavel Pack f <br /> ❑ Public i racy Dia, of Well Casing _ �j 11�}/ <br /> �j Other Del to <br /> L..-I Irrigation ❑ Type of Casing 0 <br /> Approx. ❑ Eastern <br /> E]Cathodic Protection Depth Specifications - <br /> ❑Geophysical Depth of Grout Se <br /> Other Type of Graut <br /> Repair Work Done ❑ Type of PumpH P Surface Seal Ins ~" <br /> ❑ State Work Done <br /> Well Destruction <br /> Well Diameter Sealing Material (top 50') qJ <br /> Depth Filler Material (Below 501) GJ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EJ REPAIR/ADDITION <br /> LI (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence _ Commercial Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 31feet: �----- Lot size <br /> SEPTIC TANK Water table depth <br /> [] Type/Mfg r Capacity Compartments <br /> No. Compar <br /> PKG. TREATMENT PLT. ❑ Type/Mfg } <br /> Capacity Method of Disposal-- <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> LEACHING LINE L_I No. & Length of lines <br /> FILTER BED Total length/size <br /> Di <br /> stance to nearest: Well FoundationC. <br /> SEEPAGE PITS ❑ Depth } Size <br /> SUMPS Number Property Line <br /> IJ Distance to nearest: well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 becg: "I certify that in the performance of the work for which <br /> ome subject to workman§ compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the followin <br /> this permit is issued, I shall employ persons subject to workman's compensation taws of California." <br /> The <br /> Signed X - <br /> applicant ust call for al required inspections. drawing n reverse side. <br /> SigC Complete d <br /> � <br /> Title: <br /> Application Accepted by Date: l� <br /> I PARTMEN USE ONLY <br /> �'l� Area � <br /> Additional Comments: [ 99,7 ❑ Stk 466-6781 <br /> Pit or Grout Inspection by E] Lodi 369-3621 <br /> Date <br /> Final Inspection by { ❑ Manteca 823-7104 <br /> Dated-1—euQ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 ton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> FEE BASE AMOUNT DUE } AMOUNT REMITTED ri <br /> INFO # RECEIVED BY DATE PERMIT N0. <br /> EH 13-24 REV. 10/82 I c°*p _ <br /> 14-26 ��v� i c7 0 10/82 500ti <br />