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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4. 1601 E. HAZE T ON AVE., STOCKTON, CA �' V <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J SEP Z g 1988 <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 wort,e plication is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rule � tfosrbT can Joaquin <br /> Local Health District. <br /> Job Address Ci Lot Size PM 1 <br /> Owner's Name Address Phone / 4iL 1 <br /> Contractor Address j"NO0110License No Phone 3 <br /> TYPE OF WELL/PUMIV NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION.* SYSTEM REPAIR ❑ OTHER ❑ i <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 /> ❑ Industrial- '" ❑ Opeh-Bottom-­'LI Manteca--=` " Dia. of Well Excavation Dia. of-Well-Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ! <br /> ❑ Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _ <br /> 9tr6oation —.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> ! <br /> Repair Work Done El Type of Pump H.P. -� State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') IF <br /> Depth Filler Material 18elow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i 1 DESTRUCTION i 1 (No septic system 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 <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance fti nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. H <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the_work_for-which this permit is.issued,.Lshall_not <br /> employ ariy person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawingo averse side. <br /> Signed X Title: Date: 9 _Q10-911F <br /> FOR`DEPARTMENT USE ONLY J l ' <br /> Application Accepted by Date Area 10�/ <br /> Pit or Grout Inspection by ate Final Inspection by Datel�l <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ 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 /> { <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH CKO F_ RECEIVED BY DATE PERMIT IVO. 1 <br /> n o0 <br /> -. <br /> E3-24(REV <br /> EH 1A-28 Cal <br />