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APPLICATION F0� Pr_;MiT <br /> SAN JOA4UiI, LOCAL HEALTH DISTRICT ..pp <br /> 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT NO. O1�_) <br /> Telephone (209) 466-6781 <br /> t DATE ISSUED 47 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED; <br /> (Complete in Triplicate) <br /> i <br /> Application is hereby made to the San )oaquin 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 theRules an Re ulaticns of the Sar Joaouin Local H alth District. <br /> Job Address Subdivision Name <br /> Owner's Name <br /> Address Phone <br /> Contractor's Name icense No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE (� <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 <br /> U Domestic/Private E] Gravel Pack [Tracy Dia. of Well Casing <br /> Public OtherDelta Type of Casing <br /> LJ Irrigation Approx. ❑ Eastern Specifications <br /> F—lCdthodic Protection Depth <br /> Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> U Other Surface Seal Installed by i <br /> Repair Work Done ❑ Type of Pump ' H.P. State Work Done f <br /> Well Destruction U Well Diameter Sealing Material (top 50') — <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permittedailable ifpublic <br /> thin 200fseter is <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 feet: Water table depth <br /> SEPTIC TANK EJ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance.-to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE iJ No. & Length of lines Total length/size" <br /> FILTER BED F-� Distance.to nearest: Well Foundation Property Line <br /> � t r <br /> SEEPAGE (%? ize <br /> Depth ce�—_� Si�D <br /> Number <br /> SUMUMPS SDistance to nearest: Well Foundation Property Line +PiI�Q <br /> DISPOSAL PONDS CI 4 <br /> 1 <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.subj'ect 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, 1 shall em loy persons subject to workman's Yoirftnsation laws of California." <br /> The applicant u t 11 f r all q ired inspectio plete drawing on reverse side. <br /> i <br /> Signed K le: Date: 2-6 <br /> O� <br /> E F PA USE ONLY Stk 466-b781 <br /> Application Accepted by Area <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection.b Date <br /> Manteca 823-7104 <br /> Final Inspection by 16 <br /> Date3 ❑ 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 q PERMIT ND`Q <br /> INFO <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> I` <br /> 14-26 <br />