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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT q <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 0t( <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED at J I9 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> Permit <br /> the <br /> described. This application is made in compliance with San Joaquin County 0 dinancecNo. 549tfordsewagesoriNo. 1862rforPwell/pump <br /> and the Rules nd Regulations o Ve San Joa=0, ­ uin Loc l Health District. <br /> Job Address Subdivision Name <br /> Owner's Nameddress __ _ Phone <br /> Contractor's Naicense No. ?d�'2�� Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ .,WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR n OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES .+ DISPOSAL FLD, <br /> PROP. LINE <br /> FOUNDATION AGRICULTURE WELL �` OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑Open BottomManteca <br /> ❑ Domestte/Private � Dia. of Well Excavation <br /> Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑ Other ❑ Delta --- <br /> LJ Irrigation <br /> _ Approx. ❑ Eastern Type of Casing <br /> ❑Cathodic Protection Depth Specifications <br /> []Geophysical ) �� Depth of Grout Seal-. - <br /> ❑Other ? r Type of flrout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work done <br /> Well Destruction Well Diameter — — <br /> ❑ Sealing Material (top 50') _-- <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ,REPAIR/ADDITION o septic tank or seepage page pit permitted if public sewer is <br /> Installation will serve: Re-idence _ Commercial /r Other ' available within 200 feet,) <br /> Number of living units: Number ofedrooms ��. Lot sife <br /> Character of soil to a depth of 3 feet: T � Water table depth <br /> SEPTIC TANK [] Type/Mfg � Ca pac,ity ' NoCompartments <br /> PKG. TREATMENT PLT. , --- <br /> ❑ Type/Mfg Capacity Method of Disposal <br /> Distance to neare t: Weil Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines _� _ Total= l�hgttJsiae ; V <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS De th --- <br /> P __ I Size Number /— <br /> SUMPS ❑ Distance to nearest: Well ♦_ Foundation /� `�" Property Line _�1+ <br /> DISPOSAL PONDS `� —— p y <br /> I hereby certify that I havepapplication Joaquin <br /> co <br /> pre ,red this and that the work will be done in accordance with San JoJoaquin 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 Lo become subject to workmank compensatiorl 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 must ca fn all required inspections. Complete drawing o �rse side. <br /> Signed X Title: <br /> • Date: —0 y_� >r� <br /> F R DEPARTMENT USE�LY <br /> App ,tion Accepted by �i ti _ __ Area ❑ Stk 466-6781 <br /> Additional Comments: Lodi 369-1621 <br /> Pit or Grout Inspection by <br /> Date � -- - �— - ❑ Manteca 823-7104 <br /> Final Inspection by Date <br /> ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Servicks 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952b1 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO --. <br /> S <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br />