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APPLICATION FOR PERMIT <br /> i, SAN JOAQUiN LOCAL HEALTH DISTRICT �` <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 73 O <br /> .. Telephone (209) 466-6781 <br /> DATE 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 J aqui n Local Health District. <br /> Job Address + , vision Name <br /> Owner's Name Address Phone <br /> Contractor's Name License No. 1 �� Phone IF Knn\ <br /> -V <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U CJj <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER l <br /> DISTANCE TO NEAREST: SEPTIC TANK . 1 SEWER LINES DISPOSAL FLO. PROP. LINE r - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL .h PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> cl� Industrial L,Open Bottom FI Manteca ' Dia, of Well Excavation <br /> y u <br /> Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing <br /> Public CJ Other Delta <br /> Type of Casing <br /> F, Irrigation Approx. ❑ Eastern <br /> Cathodic Protection Depth Specifications <br /> i" ' Depth of Grout Seal <br /> Geophysical <br /> Type of-Grout � <br /> r'L)Other i <br /> 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 /> TYPE OF SEPTIC ,WORK: NEW INSTALLATION E] REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> �' available within 200 feet.) t� <br /> .l Installation, will serve: Residence _ Commercial' to-'Other ' <br /> Number of living un its: Number of bedrooms Lot size { <br /> 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 Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE No. & Length of lines Total length/size } <br /> FILTER BED R Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth - -T Size Number` _ <br /> SUMPS L Distance tv nearest: ,Well� oundation Property Line <br /> DISPOSAL PONDS C <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 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 s ll 1V4uired inspect' ns. Complete drawing on reverse side. <br /> Signed X Title: [/i�"7 Date: <br /> FO E A AENT USE ONLY <br /> Application Accepted by Area Stk 6-678 ) <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date g3 Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all copies t nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> : <br /> FEE BASE I i <br /> AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, <br /> INFO <br /> EH 13-24 REV. 10/82 500,10/$2 � <br /> 14-26 <br />