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w <br />'Y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQU'iN LOCAL HEALTH DISTRICT <br /> c 6 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT 40. <br /> Telephone (209) 466-6781 <br /> 1 DATE ISSUED " <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k - <br /> (Complete in Triplicate) a <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 Joa uin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name Address I Phone <br /> Contractor's Name f n License No. f9 Q Phone Y 1��V Cl �r <br /> . a ¢ od <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION F-1 tJ' <br /> PUMP INSTAULATION SYSTEM REPAIR OTHER ❑ } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �J <br /> INTENDED USE TYPE OFiWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \\ , <br /> Industrial L Open Bottom E] Manteca Dia, of Well Excavation <br /> F-1 Domestic/Private [-] Gravel Pack ❑ Tracy Dia. of Well Casing <br /> I—] Public Other Delta <br /> Type of Casing <br /> V Irrigation IApprox. Eastern <br /> Depth <br /> Specifications <br /> Cathodic Protection P <br /> Geophysical <br /> Depth of-Grout-Seal <br /> L Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done O <br /> Well Destruction L Well Diameter Sealing Material (top 50') -- <br /> Depth Filler Material (Below 50') w -� <br /> - a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION L (No septic tank or seepage pit permitted if public sewer is (' <br /> ( available within 200 feet.) N <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 ifeet: Water table depth <br /> SEPTIC TANK Type/Mfg 1 Capacity No, Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal k <br /> SEWAGE SYSTEM o�yr Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION IC3� <br /> LEACHING LINE L No. & Length of lines Total length/size <br /> FILTER BE0Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS L Depth Size Number <br /> SUMPS L Distance to nearest: Well Foundation " Property Line f <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 <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 /> n <br /> The applicant ust call for all�requird inspections, 'Complete drawing on reverse side.�I ��,Signed X• � Title: fV�Lc�(�.� ,,�,,� �� , Date: <br /> OR DEPARTME USE ONLY ' <br /> Application Accepted by ti Area Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 a <br /> Final Inspection by �r , 'T� Date _d��J L 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 /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 3 3-te0 <br /> EH 13-24 REV. 10/82 1 _ A 10/82 500 t <br /> 14-26 G �' <br />