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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HRZELTON AVE., STOCKTON, CR PERMIT N0. _ <br /> 331 <br /> Telephone (209) 466-6781 p + <br /> � <br /> PERMIT EMPIRES 1 YEAR FROM DATE ISSUED DATE ISSUE D_3 _q-7 <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 San Joaquin Local Health District. <br /> Job Address bdivision Name <br /> Owner's Name Address .1` Phone <br /> Contractor's Nam r ense No. 1 O Phone 11�� <br /> �V <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION U SYSTEM REPAIR OTHER <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE w <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> v i <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATION5 <br /> U Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing I <br /> U Public UjOther ❑ Delta Type of Casing I <br /> V Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction U Wefll`Diameter. Sealing Material {top 50') <br /> Depth y... Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK:„NEW INSTALLATION EJEPRI ,ADDITION 7,n-"(N, septic tank or seepage pit permitted if public sewer is V t <br /> - 6vailable within 200-feet.) <br /> Installation will serve: Residence Y Commercial Other <br /> Number of living units __I_"_ Number of bedrooms Lot size �7 ! <br /> Character of soil to a depth of 3 feet: . , Water table depth y�'!0 <br /> SEPTIC TANK Cj 7 pe/Mfg Capacity No. Compartments ` <br /> PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal. <br /> SEWAGE SYSTEM- Distance to nearest:' 'Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No.-& Length'-of lines' Total length/size 01-1 rR <br /> t j <br /> FILTER BED ❑ Distance'_to nearest Well Foundation P�perty.Line S <br /> SEEPAGE PITS Depth '.�� 'yrrSiz (.1 L Number f <br /> .el <br /> SUMPS ` �� Distance-to-nearest: �Idel'1 � 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'Taws, and rules and regulations--of the San Joaquin Local Health District. 0.1 <br /> Home owner or licensed agent's signature certifies the following:” I'certify that in the performance of the work for which this <br /> 1 permit is issued, Ishall not employ any person in'such manner as .to become subject to workman5 compensation-laws of California." <br /> " Contrac'tor's fii-ring"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 applicamust cal for all required inspections. Complete drawing o reverse side. <br /> Signed X Title: �J, — Date• <br /> FO ARTMENT USE ONL <br /> Application Accepted by Area (] Stk 466-67$1 <br /> Additional Comments: <br /> Lodi 369-3621 <br /> Pit or Grout Inspection by s Date U Manteca 823-7104 <br /> Final" Inspec$ion'by� " Date �7" --Traey_ 835-6385 <br /> Applicant - Return all copies to: Environmental H lth Permit/Services 1601 E. Hazelton Avif, P.O. Box 2009, Stk., CA' 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE .q' PER�TS NO..7 ±y <br /> INFO -�1�-3 0 / 4~ <br /> EH 13-24—REV.`1.0.,82.. <br /> 14-25 <br />