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S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. J <br /> Telephone (209) 466-6781 <br /> GATE ISSUED <br /> PERMIT ExPIRES 1 YEAR FROM 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 and Regulations of the San Joaquin Local Health District, <br /> Job Address :5±KL1 Subdivision Name <br /> Owner's Name o..r Y' <br /> Address X24E , C Phoneg y3 sS� <br /> Contractor's Name O VJ Y\. License.No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM -REPAIR ❑ OTHER ❑} <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 'r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation i <br /> Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑Other ❑ Delta Type of Casing <br /> Irrigation Approx. ❑ Eastern Specifications <br /> ❑Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout <br /> ❑)Other Surface Seal Installed by <br /> i <br /> Repair Work Done [j Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') — <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 „h <br /> available within 200 feet.) U 1 <br /> Installation will serve: Residence — Commercial _ Other <br /> f Number of living units: Number of bedrooms Lot size <br /> I Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM �J Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <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 Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑I <br /> w <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 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 applicant m cal far all re inspe ions Complete drawing on reverse side. <br /> Signed X <br /> ` Title: afl Date: <br /> i <br /> FOR DEPAR NT Iii Stk . 466-6781 <br /> Application Accepted by Area n _ �4 <br /> 369-3521 <br /> Additional Comment � ❑ Lodi <br /> Pit or Grout Inspection by Date ❑ Manteca 823-71D4 <br /> Final Inspection by - <br /> Date Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95241 <br /> FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y i1o) g- jZj INFO 4- 10 <br /> - r O o�� o <br /> EH 13-24 REV. 10/82 �f f <br /> � 14-26 �{ <br />