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w APPLICATION FOR PER'•:" <br /> SAN JOAQLi.', LOCAL Nc41TH 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 <br /> described. This applicati n is ma irl�ompliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rul e 1�i brat arL.7oaouin Local Health District. <br /> Job Address y ,, il; G`rfc/iio,,/ Subdivision Name <br /> Owner's Name p Address Phone <br /> Contractor's Name /./ a icer License No. YY'%- SY/ Phone s f- o i <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U \ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I_JIndustrial U Open Bottom Fj Manteca Dia. of Well Excavation <br /> Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing <br /> L7 Public rl Other Delta Type of Casing <br /> F, Irrigation Approx. E]Eastern U <br /> ❑Cathodic Protection <br /> Depth Specifications <br /> Depth of Grout Seal <br /> 17 Geophysical <br /> Type of Grout <br /> U Other <br /> Surface Seal Installed by <br /> Repair Work Done EJ Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) _ <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION / 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 ci Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well We" Foundation Property Line /l' <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS IJ Distance to nearest: Well Foundation Property Line /or <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. <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 employ persons subject to workman's compensation laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X � >�' <br /> Title: Date: y-� Y <br /> DV/RTMENT USE ONLYStk 466-6781 <br /> Area <br /> Application Accepted by ��/ _ <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by 1 Date 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 MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE [PERMIT NO. <br /> INFO B v7 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />