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00& <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephore (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> r <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 Ordin��� <br /> for sewage or No. 1862 for well/pump a <br /> and the Rules and a ulaa't`ions of the Sa oaquin .Local Health District. r 0 <br /> Job Address / �J � Z _ Subdivision Name <br /> Owner's Name Address Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ ' <br /> PUMP INSTALLATION SYSTEM REPAIR U OTHER Lk <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ,d <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V <br /> I industrial U Open Bottom Manteca Dia. of Well Excavation <br /> L Domestic/Private F-1 Gravel Pack ❑Tracy Dia. of Well Casing <br /> �] Public F-1 Other [] Delta Type of Casing 1 t <br /> r LjIrrigation Approx. [] Eastern <br /> Depth Specifications <br /> Cathodic Protection Depth of Grout Seal <br /> Geophysical Type of Grout <br /> LJ Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> . 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION L (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 f t: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments +I! <br /> PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal I <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line ttt <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines 90 Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS �j Depth size Number <br /> SUMPS a Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS L <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 workman5 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 Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Area Stk 466-6781 j <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton .Ave., P.O.-Box 2009, 5t k., CR 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY a, ,DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 D 10/82 500 <br /> b <br /> 14-26 <br /> `i <br />