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APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> : <br /> 1601 E. HAZELTQ N AVE., STOCKTON, CA PERMIT N0. �e <br /> Telephone (209) 466-6781C� <br /> DATE ISSUED 4.0 <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 /> and the Rules qno Regul tions of the"San Joaquin Local Health District. <br /> ,lob Address V i(^ Subdivision Name <br /> Owner's Name Address Phonew <br /> Contractor's Name..(,CE License No, � %1) Phone , <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `,� <br /> PUMP 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 /> .4 <br /> INTENDED USE TYPE OF WELL- PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U open Bottom ❑ Manteca Dia. of Well Excavation <br /> - ❑ Domestic/Private Gravel Pack Tracy Dia, of Well Casin <br /> ❑ Public ❑ Other ❑ Delta, ,. ."T_,. .. ... .� <br /> r <br /> V Irrigation Approx. Eastern Ty of Casing <br /> F-1Cathodic Protection Depth Specifications <br /> Depth of Grout Seal <br /> ❑Geophysical _ <br /> Type of Grout ✓ ' `� <br /> Other 4 <br /> U FFF • x. Surface Seal Installed by cx\1 <br /> Repair Work Done ❑ `Type of Pump H.P. State Work Done !`t <br /> Well Destruction ❑ ',Well Diameter` - —Sealing`Ito al (top 50') <br /> �. <br /> iDepth 50') <br /> TYPE OF SEPTIC WORK:; NEW INSTALLATION LI REPAIR/ADDITION j"i(No septic tank or seepage pit.permitted if public sewer is C <br /> s ,r — available within 200 feet. <br /> serve: ) <br /> Installation will Residence X Commercial _ Other , <br /> ✓ <br /> Number of living units: Number of bedrooms_. . -.1_ot size _ _�_ IS ?c <br /> Character of soil to a depth of'.3_,feet: �D(I R, _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. L Type/Mfg CapacityMethod of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well oundation Property Line j <br /> DESTRUCTION E Ck{ } <br /> LEACHING LINE ❑ No'. & Length of lines Total length/size <br /> FILTER BED Distance to. nearest-_.. Well _Foundation Property-Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS Distance to nearest:! Well Foundation Property Line <br /> DISPOSAL PONDS f <br /> a <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 agents 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 workmanIs 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 /> thi�applica <br /> ermit is issued, I shall - ploy persons subject to workman's compensation laws of California." <br /> The st a fo a 1 e uir inspIctions. CompleteSigTitle: Date: <br /> � DE$�ARTMENT USE ONLY <br /> Application Accepted by Nle 07,V Area �_ Stk 56=6781 <br /> Additional Comments: �] Lodi 21 <br /> Pit or Grout Inspection by Date LJ Manteca`823-7104 p <br /> Final Inspection by Date /,30- Tracy 835-6385 <br /> Applicant - Return all CoVi ta: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box-2009,',Stk., CA 95201 <br /> � t <br /> FEE BASE AMOUNT ,DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> r <br /> EH 13-24 REV. 10/82 + <br /> ,. 10/82 500 <br /> 14-26 <br />