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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 Y <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 / p Subdivision Name <br /> Owner's Name _��� �/7t1 Address '` /�IMAPhone <br /> Contractor's Name , License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> P <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom Manteca Dia. of Well Excavation F <br /> Lj Domestic/Private E]Gravel Pack Tracy Dia, of Well Casing <br /> 17 Public �Other EJ Delta <br /> Type of Casing <br /> [J Irrigation Approx. Eastern <br /> Depth Specifications <br /> r ❑Cathodic Protection P Depth of Grout Seal <br /> EJ Geophysical 0 <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> F Repair Work Done Type-of Pump H.P. -- - - `State Wofk`Done <br /> , Well Destruction F-1 Well Diameter Sealing Material (top 50') y <br /> Depth Filler Material (Below 50') <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR%ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> If---Commercial <br /> available within 200 feet.) <br /> Installation will serve: Residence _ _ Other <br /> Number of living units: Number of bedrooms Lot size f !� <br /> Character'of soil 'to'a"deptF bf 3'feet — .i5VA - — �^"`°� Water table depth <br /> �_— <br /> SEPTIC TANK E] Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal! <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION 0 <br /> LEACHING LINE No. & Length of lines Ja ' of 1L'1ngth/size fp )( <br /> FILTER BED Distance to nearest: Well Foundation ffe= Property Line al4�y <br /> SEEPAGE PITS .Cj ._ Depth Size Number <br /> SUMPS ,U "' Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ' <br /> r , <br /> nr inarmninrrrrrr_ <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 workman� 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 .empioy_per_sons subject to workman's compensation laws of California." <br /> The applicant must cal fo 41 requ'red inspections. Complete drawing on reverse side. <br /> Signed K Title: Date: <br /> F QEPARTMENT'USE ONLY <br /> Application Accepted, by - Area15 E] Stk 466-6781 to 6 <br /> Additional Comments: 0 Lodi 369-3621 <br /> Pit or Grout Inspection Date -�anteca 823-7104 <br /> Final Inspection by _ r Qom.` Date C] Tracy 835-6385 <br /> Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 <br /> FEE BASE AMOUNT UUE 'AMOUNT REMITTED RECEIVED BY �' I ­DATE" "s PE'RMIT-ND. <br /> INFO <br /> - 1 S, <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />