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APPLICATION FOR PFRM: <br />SAN jGAQLi'1 LOCAL HEALTH D",STRICT ? <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 />and the Rules and Regulations of the San <br />Joaquin Local Health District. <br />Job Address / dc,4G <br />Subdivision Name <br />Owner's Name <br />Address �i.�- �- Phone <br />Contractor's Name <br />License No. Phone f� �,� a 9 <br />7 <br />TYPE OF WELL/PUMP WORK: NEW WELL <br />WELL REPLACEMENT DESTRUCTION ❑ <br />�` <br />PUMP INSTALLATION SYSTEM REPAIR [ OTHER [ <br />i <br />DISTANCE TO NEAREST: SEPTIC TANK <br />SEWER LINES DISPOSAL FLO. PROP. LINE <br />c{) <br />FOUNDATION <br />AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />V � <br />INTENDED USE TYPE OF WELL <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />--�/ <br />[ Industrial U Open Bottom <br />[:]Manteca Dia, of Well Excavation <br />Domestic/Private [ Gravel Pack <br />❑ Tracy Dia, of Well Casing <br />[ Public [ 0ther <br />[ Delta <br />[j Irrigation Approx. <br />Type of Casing <br />[ Eastern <br />[ Cathodic Protection Depth <br />Specifications <br />[ Geophysical <br />Depth of Grout Seal <br />[ Other <br />Type of Grout <br />Surface Seal Installed by <br />f. , <br />Repair Work Done E] Type of Pump <br />H.P. State Work Done <br />Well Destruction [ Well Diameter <br />Sealing Material (tap 50') <br />Depth <br />Filler Material (Below 50') <br />TYPE OF SEPTIC WORK: NEW INSTALLATION [� <br />/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br />200 <br />( /� <br />t/ a <br />Installation will serve: Residence _ <br />available within feet.) <br />Commercial _ Other <br />Number of living units: _� Number <br />r <br />of bedrooms — Lot sizefi v <br />Character of sail to a depth of 3 feet: <br />SEPTIC TANK Type/Mfg <br />Wat table depth <br />` C r%6yLawJ� <br />PKG. TREATMENT PLT. Type/Mfg <br />LJ <br />Capacity Method of Disposal <br />SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br />DESTRUCTION <br />LEACHING LINE No. & Length of <br />lines / '116, J, Total length/size <br />FILTER BED Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS] Depth 2 !�' ' <br />Size 331, Number <br />SUMPS F1 Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS [ <br />1 <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 />The applica 11 for al re uired spections. Complete drawing on ride.verse s <br />Signed X Title: Date: <br />FP4 DEPARTMENT USE ONLY <br />Application Accepted by Area —� �tk 466-6781 <br />Additional Comments: Lodi 369-3621 <br />Pit or Grout Inspection by e 1 [ Manteca 823-7104 <br />Final Inspection by Date�_ SIL Tracy 835-6385 <br />Applicant - Return ail cop to: Environmental Health Permit/Services 160 E. arreltnhve., P.D. Box 2009, Stk., CA 95201 <br />FEE � BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br />INFO ` ,j �� � � � E � 93—, U -SIN <br />EH 13-24 REV. I0/62 a 10182 500 <br />