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APPLICATION FOR PERMIT <br /> SAN JOAQU'IN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 PERMIT NO. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) <br /> t <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 n <br /> Subdivision Name <br /> Owner's Name ' Address <br /> Contractor's Name Phone <br /> License No. / �/ Phone 1 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT �t 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 <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I] Industrial ❑ Open Bottom Manteca ` <br /> ❑ Dia. of Well Excavation <br /> Lf Domestic/Private ❑Gravel PackTrac <br /> Public ❑ y Dia. of Well Casing <br /> 17 ❑ Other ❑ Delta <br /> E irrigation Approx. Eastern Type of Casing <br /> [Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> ❑Other Type of Grout <br /> Repair Work Done E] Type of Pump H.p. Surface Seal Installed by <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IZj REPAIR/ADDITION I No septic tank or seepage - <br /> � ( ppit permitted if public sewer is <br /> Installation will serve: Residence _ Commercial {l Other available within 200 feet.) <br /> Number of living units: Number of bedrooms ! G 7 N <br /> Lot size v <br /> Character of soil to a depth of 3 feet: `, ° <br /> Water table depth v <br /> SEPTIC TANK � Type/Mfg Ca acit L�C�— No. Compartments �C <br /> P Y �, <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well ' <br /> DESTRUCTION ❑ oundation (� Property Line U� <br /> LEACHING LINE No. & Length of lines f <br /> 1 Total length/size C <br /> FILTER BED Distance to nearest: Well 41 Foundation �7 �� Property L e • `j <br /> SEEPAGE PITS gepth " Size fes( �{' Number <br /> SUMPS ❑K Distance to nearest: Well Foundation \ Property LineRAvi_-J <br /> DISPOSAL PONDS ❑} � �' l�r. L <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 mu - or-a1H�J ired n ections. Complete awing on Qverse side. <br /> Signed X ' , <br /> Date: <br /> /> F jj, 1 P{�RTMENT USE LY <br /> Application Accepted by �� . %;/!t� Area C Z ® Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date ❑ Manteca 823-7104 <br /> Final Inspection by Date3 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: E ronmenta4ealth�Permit/�Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 <br /> 14-26 ��� 10/82 500'x' <br />