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x <br /> APPLICATION FOR PER;,;; <br /> SAA' JOAQUi"; LOCAL HEFLTH DISTRICT <br /> 1601 E. HA2ELTON AVE., STOCKTON, CA 473-93 <br /> Q 3 <br /> Telephone (209) 466-6781 PERMIT NO. 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE 15SUED <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 Count Ordinance No. 549 for Sewage or No. 1862 for well <br /> and the Rules and Regulations f the SapJoaquin Local Health District. y 9 <br /> Job Address /pump <br /> Owner's Name 1111 Subdivision Name` <br /> Address t <br /> Contractor's Name ( �L Phone� License No. <br /> Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL <br /> WELL REPLACEMENT C DESTRUCTION � CP <br /> INSTALLATION SYSTEM REPAIR C <br /> DISTANCE TO NEAREST: SEPTIC TAMC OTHER ❑ Y <br /> �__ SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE <br /> OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PRCBLEM AREA _ <br /> EJ Industrial CONSTRUCTION SPECIFICATIONS U} <br /> U Open Bottom Manteca Dia. of Well Excavation ' <br /> F_; Domestic/Private E] Gravel Pack Trac <br /> I—] PublicEj y Other Delta <br /> Dia. of Well Casing <br /> L, Irrigation Type of Casing <br /> Approx. � Eastern g <br /> FICathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> jJ Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H p <br /> State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (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: <br /> SEPTIC TANK ❑ Type/Mf Water table depth <br /> Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM <br /> DESTRUCTION 0 Distance to nearest: Well Foundation Property Line <br /> +—I <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS �� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONTIS <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 r regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agen s signat e certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I shall t employ a y person in such manner as to become subject to workman§ compensation laws of California.' <br /> Contractor's ing or sub- ntracti nature ertifies the following: "I certify that in the performance of the work for which <br /> this permi i sued I sh I em s sub ect to workman's compensation laws of California." <br /> The appTic t t cal for 1 re it d i i . Complete drawn on reverse side. <br /> Signed X 3 Title: Date: <br /> D P RTMEN SE ONLY <br /> Application Accepte y Area ! 15� t 466-6781 <br /> Additional Comments Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> FinalInspection by OILDate — ❑ Tracy 835-6385 <br /> Applicant - Return all copies to. i onme al Health Permit/Services 1602 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT D AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br />