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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., 5TOCKTON, CA <br /> Telephone (209} 466-6781 PERMIT N0. <br /> �1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> N {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 /> ff j Job Address ca, Subdivision Name <br /> Owner's Name /,� `" 6'D 41,4 0^/ Address) //12 Phone <br /> '� 6 f�--?p�S <br /> i) Contractor's Name <br /> E .License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL y <br /> 9 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ""'"'-'"."--'PUMP-INSTALLATION ❑---•--SYSTEM REPAIR ❑ OTHER­ <br /> DISTANCE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> !� FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> b INTENDED USE TYPE OF WELL PROBLEM AREA _ "- ��-—^• <br /> y CONSTRUCTION SPECIFICATIONS <br /> !( J Industrial ❑ Open Bottom Manteca <br /> ❑ I Dia. of Well Excavation <br /> LJ Domestic/Private ; Gravel Pack Trac <br /> I: ❑ - ❑ y Dia. of Well Casing <br /> ifPublicM -Ej Other ❑ Delta <br /> ie LJ Irrigation Type of Casing <br /> Approx. ❑ Eastern ; <br /> ❑Cathodic Protection Depth $ Specifications <br /> ❑Geophysical Depth of Grout Seal <br /> ! ❑Other Type of Grout <br /> I1 Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> fWell Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> F <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITSQN L( a(No septic tank or seepage pit permitted if public sewer is <br /> iii <br /> Installation will serve: Residence _ Commercial Other available within 200 feet.) <br /> �# Number of living units: Number of bedrooms Lot size Z <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> Ca acity No. Compartments <br /> P <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM <br /> DESTRUCTION L�'r;r distance to nearest: Well Foundation,.. Property Line__ <br /> ° <br /> FLEACHING LINE ❑ No. &Length of lines Total length/size; . <br /> ILTER BED ❑ Distance to nearest: Well FJ. oundation Property Line <br /> SEEPAGE PITS Cj Depth Size Number <br /> a <br /> SUMPS ❑I Distance to nearest: Well FoundationProperty Lane <br /> .i DISPOSAL PONDS <br /> EI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> 11ordinances, 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 /> liCpermit is issued, I shall not employ any person in such manner as to become subject to workmanIs compensation laws of California." <br /> ( ontractor'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 appli st call fo�dlr quired inspections. Complete drawl�go�nsraeverse side. <br /> Signed. w Title: v�"'�L <br /> Date: <br /> F�A P�ARg�IENT USE ONLY <br /> !i Rpplicat on Accepted by �icril2 Area Stk 466-6781 <br /> I� Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by <br /> Date ❑ Manteca 823-7164 <br /> Final Inspection by f <br /> Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 16 1 E, azelton Ave., P.O. Box 2009, Stk., CA 95201 4 <br /> it FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> S INFO <br /> N b 2- <br /> 0 13-24 <br /> EH 14-26 REV. 10182 rf� Lo Cf451 10182 500 1 <br />