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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH 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 application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules n Regulations of the San Jqu.n Local Health District, <br /> Job Address q 6 k/ G1C) Subdivision Name <br /> Owner's Name !Q V© Address 6 Phone <br /> Contractor's Name 4L C License No. ]/ a4 Phone <br /> W <br /> TYPE OF WELL/PUMP WORK: NEW WELL ELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR <br /> �. �� ❑ OTHER [� l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE g 6e <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _ — PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom MantecaExcavation <br /> ❑ Dia. of Well <br /> estic/Private ravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Pubiic ❑j Other [] Delta <br /> LI Irrigation Type of Casing /� (f <br /> Approx. Eastern <br /> [] Cathodic Protection Depth Specifications <br /> ❑Geophysical Depth of Grout Seal <br /> ❑Other Type of Grout <br /> Surface Seal Installed by jV n <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done ^�J <br /> Well Destruction F1Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence — Commercial Other available within 200 feet.) <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 �j Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposa <br /> Distance to nearest: Well FoundationProperty Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Humber <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 applic t must call for a quired inspections. Complete drawing pn M- �- <br /> side. <br /> Signed X 1VALll i�hVi �f 1Title: Date i s J U /I N <br /> plication Accepted by DE MENT USE ONLYG Area oYr Stk 466-6781 <br /> Additional Comments: [J Lodi 369-3621 <br /> Pit or Grout Inspectia Date -2 Manteca 823-7104 <br /> Final Inspection by Date 6� -�1 Q Tracy 835-6385 <br /> Applicant - Return all copie Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO DATE PERMIT N0. <br /> a� <br /> EH 13-24 REV. 10/82 <br /> 14-26 - 10/82 500 <br /> i <br />