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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT D <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED � <br /> PERMIT EXPIRES i 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 and Regulations of the SaJoaquin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name Address Z Phone <br /> Contractor's Name ! y License No. Phone . <br /> of <br /> TYPE OF WELL/PUMP WORK: NEW WELL L) WELL REPLACEMENT DESTRUCTION L <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK LQSEWER LINES DISPOSAL FLD.'_D PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS m 0 <br /> L Industrial U Open Bottom []Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑Other ❑ Delta Type of" Casing <br /> L Irrigation Approx, Eastern <br /> Depth Specifications <br /> Cathodic"Protection Depth of Grout Seal <br /> ❑Geophysical Type of Grout `, ! <br /> 0 Other <br /> Surface 5eal.Installed by <br /> Repair Work Done Type of Pump ' H.P. t" State Work Done S Ta(l e J. <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is ; <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ 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 ❑ JI <br /> LEACHING LINE L 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 LI Distance to nearest: Well Foundation Property Line r <br /> DISPOSAL 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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, p <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 hi Tor sub-contracting si ture certifies the following: "I certify that in the performance of the work for which <br /> this permit is ' sued, I shall employ ns subject to workman's compensation laws of California." <br /> The applicant mu t call for a�11 requ"' inspections. Complete drawing on reverse side. <br /> Signed X <br /> F Title: Date: <br /> R DEPARTMENT USE ONLY r , ❑ <br /> Application Accepted by Area _a _� Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by _ n Date / ❑ Manteca 823-7104 <br /> Final Inspection by E41 Date ({¢ Tracy 835-6385 <br /> Applicant - Return all copies to: FnvironmentalHeaPermit/Services 1601 E. HazeltA Ave. P.O. Box 2009, Stk., CA 95201 <br /> FEE BA E AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT N0. tea <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />