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APPLICATION FOR PERMIT { <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � w <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 /> a R 1 s ' 'Regulati s t o San Joaquin Local kJealth DistrictY <br /> * <br /> ab rens .n ii68li siorY me <br /> Owner's Name Address (p �( Phone <br /> Contractor's ' License No Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION ❑ <br /> 1 <br /> ?UMP 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 /> Industrial.. (J Open Bottom Manteca � 6ia. of Well Excavation <br /> [� Domestic/Private E]Gravel Pack ❑Tracy Dia. of'iWell Casing <br /> Public F_�Other Delta <br /> Type of;Casing <br /> U Irrigation -Approx,-- .Q Eastern- - i r <br /> Depth Specifications <br /> ❑ Cathodic Protection p * _ R� <br /> Depth'of <br /> U Geophysical �U Seal <br /> V v <br /> Other i Type of Grout <br /> Surface 'Seal.Installed by <br /> Repair Work Done [] Type of Pump H.P. State Wo.W Done <br /> t <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50')/d't <br /> f <br /> Depth Filler Material (Below 50')"' <br /> E . <br /> TYPE OF SEPTIC'WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j� (No septic tank or seepagq pit permitted if public sewer is <br /> � ►; <br /> ,available within 200 feet.) <br /> Installation will serve: Residence * Commercial Other N T <br /> Number of on <br /> units: Number of b rooms q Lot size e <br /> a. li <br /> Character of soil to a depth of 3 feet: �-rj4l � 4 Waterttable depth Z IA i <br /> —v <br /> SEPTIC TANK oFr Type/Mfg 1 Capacity /(a" i No! Compartments oZ _ <br /> PKG. TREATMENT PLT. Type/Mfg f Capacity JMethod,of Di'sposa�I ; <br /> Distance to nearest: Well .Std Foundation /0 ^ Property Line i <br /> LEACHING LINE No. & Length of lines Total length/size a c� <br /> FILTER BED Distance to nearest: Well 5-00 Property Line <br /> .� +... <br /> SEEPAGE PITS Depth _ Size k JO Number <br /> SUMPS Distance to nearest: Well Foundation Property Line 57 <br /> DISPOSALPND <br /> 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 /> lh ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I Home owner or licensed agent's signature certifies the following: rI 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!s 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 /> The applica must cal fo all required inspections. Complete drawing on verse side. <br /> Signed X _ Title: Date: <br /> F DEPARTMENT USF,ONLY.' � <br /> Appl i tion Accepted by 1;(_144ea ) 2— [] Stk 466-6781 <br /> Additional Comments: [] Lodi 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 to: Environmentaf 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 />