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APPLICATION FOR PERMIT <br /> SAN JOAQbiI: LOCAL i'EALTH DISTRICT I � <br /> 1501 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 San Joaquin Local Health District. <br /> Job Address 5? Subdivision Name r <br /> Owner's Name Address <br /> Contractor's Name License No. zY r"o"e <br /> UV <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT E] DESTRUCTION U U1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR I— OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROF. LINE (� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ll�� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 U <br /> industrial Open Bottom 71 Manteca Dia. of Well Excavation <br /> - <br /> U Domestic/Private [:]Gravel Pack ❑ Tracy Dia. of Well Casing <br /> 17 Public F-10ther Delta Type of Casing <br /> 7 Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> 17 Geophysical Type of Grout <br /> [—lather Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION R AIR (No septic tank or seepage pit permitted if public sewer is <br /> / available within 200 feet.) <br /> Installation will serve: Residence 'I Commercial Other ^ <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water, tabledepth <br /> Compartments <br /> SEPTIC TANK � Type/Mfg Capacity No. Com P <br /> PKG. TREATMENT PLT. 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 U Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line_ . . <br /> SEEPAGE PITS Depth Size <br /> 33 Jf Number <br /> SUMPS U Distance to nearest: Well f )/f-Foundation Property Line <br /> F <br /> DISPOSAL PONDS ❑ �T <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 ':t call 'fr l required inspections. Complete drawing on reverse side. <br /> Signed X ,Yf' Title: Date: i- <br /> - <br /> OR-DEPART ITUSE NLY I�� Stk 466-6781 <br /> Application Accepted by Area <br /> Lodi 369-3621 <br /> Additional Comments: <br /> or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date �i /�- fes Tracy 835-6385 <br /> Applicant - Return all copies to: Environmertal He th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> -BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO `�V <br /> + 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />