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i <br /> APPLICATION FOR PERMIT 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA JUN 16 1984 <br /> Telephone (209) 466-6781 ` <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SHEALTH <br /> QU DISTRICT L <br /> ' ( Complete in Triplicate) <br /> App lication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the Rules and the work iRegulations of he Sann described. This ication Joaquin <br /> is <br /> made in compliance with San Joaquin Conty Ordinance No.549 for sewage or No. 1 for well/pump <br /> Local Health District. <br /> y� 4!7 Lot Size PM <br /> Jab Address <br /> ,®/d1 C'ty <br /> 4 <br /> Phone <br /> �y Address <br /> f Owner's Name ��' <br /> V <br /> Contractor's Name <br /> � _ License No. d`° Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR W' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing A <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation "�(l� <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy YP <br /> LJ Public ❑ Other [I Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. De h ❑ Eastern Surface Seal Installed by <br /> H•P. State Work Done <br /> 4 <br /> Repair Work Done ❑ Type of Pump ,, <br /> Well Destruction Ll Well Diameter Seating Material (top 50'i <br /> i Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system 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 i <br /> Character of soil to a depth of 3 feet{ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 3 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I . Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance'to nearest: Well Foundation Property Line <br /> '1 <br /> SEEPAGE PITS Cl Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> d 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 ordinances, state laws, and <br /> 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 permit is issued, I shall not <br /> employ any person in such manner as_to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> i certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu call for re)uired inspections. Complete drawing on erre side. <br /> Date: <br /> Signed d4-�` Title: <br /> I FOR DEPARTMENT USE ONLY <br /> Ab <br /> Application Accepted by D �, Area <br /> Pit or Grout Inspection by Date Final Inspection Date IC , y <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-Mi ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Returnall copies to: Enviio nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. box 2009, Stk., CA 95201 <br /> FEE CK# RECEIVED BY DATE PERMI7"NO. <br /> k INFO AMOUNT DUE AMOUNT REMITTED CASH G <br /> + EH 1324(REV.19!631 4 OSa V\ s ����� <br /> EH 1426 <br />