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4 APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT ��J n <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. S <br /> Telephone (209) 456-6781 <br /> DATE ISSUEp [f <br /> PERMIT EXPIRES 1 YEAR FRCM 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 Joaquir 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/ �� 1 Subdivision Name <br /> Owner's Name Address'! Phone .--- <br /> Contractor's Name ,�, ,�✓S License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U Kr l <br /> 1 € <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE W <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V <br /> Industrial U Open Bottom Manteca Dia, of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public [j Other [ Delta <br /> e Type of Casing M <br /> Lj irrigation Approx. ❑ Eastern <br /> Depth Specifications i <br /> Cathodic Protection i1 <br /> Depth of Grout Seal <br /> L]Geophysical <br /> Type of Grout <br /> ❑Other <br /> Surface Seal Installed by <br /> Repair Work Done E] Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Mater ial (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ,�q (No septic tank or seepage pit permitted if public sewer is <br /> X available within 200 feet.) <br /> Installation will serve: Residence )e Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size 5_a. <br /> Character of soil to a depth of 3 feet:- _ Water table depth <br /> SEPTIC TANK Type/Mfg : Capacity No. Compartments r /� <br /> PKG. TREATMENT PLT. ❑ Type/Mfg ' Capacity Method of Disposal l(�� <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line i <br /> DESTRUCTION ❑ r 1 <br /> LEACHING LINE No. & Length of lines —= .64 <br /> "' Total length/size <br /> FILTER BED E] Distance to nearest: Well Foundation r Property Line <br /> SEEPAGE PITS Depth It Size 40 Number <br /> SUMPS Distance to nearest: Well Foundation � Property Line <br /> l <br /> DISPOSAL PONDS D <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, 1 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 sig ture certifies the following: "I certify that in the performance of the work for which <br /> this permit i issued, I shall employ per ns,subject to workman's compensation laws of California." <br /> The applic t c 11 for 1 requir inspections. . Complet drawin o reverse side. �i <br /> Signed r a Title: .4/ Date: <br /> F DEP MENT USE ONLY ®+� '�' Stk 466- <br /> Application Accepted by � Area <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date ,{�`��rj ❑ Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all co a o: Environmental 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 N0. 1 <br /> INFO <br /> 0 'g3 32 3 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />