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APPLICATION FOR PERMIT <br /> SAN JOAQb-LN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephcne (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicatior 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 d Re/g�ulations of the San Joaquin al Health District. <br /> Job Addre� Y • Subdivision Name <br /> Owrer's Name Address at 1Pd • Phone <br /> Contractor's Name License No. Phone • <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION -- II, <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE V v <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TY^E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation �!" <br /> ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public Other Delta <br /> Type of Casing , <br /> 71 Irrigation Approx. Eastern <br /> Depth Specifications , <br /> ❑Cathodic Protection Depth of Grout Seal <br /> F1 Geophysical <br /> Type of Grout <br /> LJ Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') �} <br /> Depth Filler Material (Below 50') <br /> 01 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other lJ <br /> Number of living units: Number of bedrooms Lot size <br /> Character of sail 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 SYSTEMDistance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE Sr-�No. & Length of lines To aOeigth/size <br /> FILTER BED F-1 Distance to nearest: Well Foundation Property Line <br /> 02 i <br /> SEEPAGE PITS Depth _ �� Size ` Number <br /> SUMPS L_ Distance to nearest: Weil Four'. ation ` <br /> Property Line <br /> DISPOSAL PONDS }' " r`w• ' <br /> I hereby certify that I have prepa;.9d 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 Sam.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-contr ting signature certifies the fol Iowing:,4'10.certify that in the performance of the work for which <br /> this permit is issued, I shall pla4y persons subject to workman's compensation laws of California." <br /> The applicant t ca far d inspections, Comm*6 <br /> or reverse side. <br /> Signed x Title: .rr� tL)A� .,� _" Date: s/ <br /> r <br /> FO PARTMENT USE ONLY Stk 466-6781 <br /> Application Accepted by Area <br /> Additional Comments: ,�' Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6365 <br /> Applicant - Return all cup!e to: Environmental Aedlth Permit/Sery ces 1601 E. Hazelton Ave_ P.O. Box 2009, Stk., CA 95201 <br /> S <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> I INFO <br /> 44 <br /> 1a-1 ~Y_3 73- 3 <br /> EH 13-24 REV. 10/82 L, 10/82 500 <br /> 14-26 <br />