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£� <br /> APPLICATION FOR PERMhd�' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ �( <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. + <br /> Telephone (209) 466-6781 <br /> / DATE ISSUED I <br /> PERMIT EXPIRES i 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 Jo q in County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulatio f tjie San Joaquin Local H It is rict, Q <br /> Job Address u i i ion Name 8 <br /> Owner's Name ,_ „, rr; '1t� ,--- _ Address Phone <br /> 1 �` / License No. Phone t <br /> Contractor's+Name " �� �`�?'C�. �,�;.' _ <br /> TYPE OF WELL/PUMP WORK: NEW WELL �] ' WELL REPLACEMENT [] DESTRUCTION �. <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> 1. DISTANCE TO NEAREST: SEPTIC TANK-. SEWER LINES DISPOSAL FLD. PROP. LINE 1 ° <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ]� <br /> 17 Industrial ❑Open Bottom 0 Manteca Dia, of Well Excavation <br /> Domestic/Private Gravel.Pack Tracy �,� Dia. of Well Casing <br /> Public Other [] Delta i ` Type of Casing <br /> Lj Irrigation ^, Approx.* Eastern 'Specifications <br /> Cathodic Protection-L,, Depth Depth of Grout Seal (� <br /> L Geophysical v ` <br /> f` Type of Grvut, a p � <br /> Other Surface Seai A talled by s of <br /> Repair Work Done �J Type of Pump '"'� H:P. State Work.Done <br /> s <br /> Well Destruction F-1WellDiameter Sealing Material (top 501) • ~ <br /> Depth _. Filler Material (Below 50' <br /> i <br /> � Yi <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADD TION U (No septic tank'dr'seepage pit permitted if public sewer is <br /> \`*� ava- lable within 200 feet.) <br /> Installation will serve: Residencej Commercial Other ' <br /> Number of living units; �_ Number of bedrooms � -'-� .°Lot size �-f+., V <br /> + <br /> Character of soil to depth of 3 feet; /r table depth, f <br /> SEPTIC TANK Type Mfg - Ca'pacity ,� mpartments <br /> PKG. TREATMENT PLT. Type Capacity of DisposalSeptic Tank Distance to nearest: We31 Foundation ine / , <br /> Destruction <br /> LEACHING LINE No. & Length of lines I" �7 Tota-1 ength/size _17 <br /> FILTER BED Distance to nearest: Well fi Founda ' n .f Property Line <br /> SEEPAGE PITS Depth �7 size r1 Number , <br /> SUMPS U Distance to nearest: Wel Found lon "property Line <br /> DISPOSAL"PONDS \ �` <br /> I hereby certify that I have prepar d this application and that the work wi be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules,and regulations of the San Joaquin Local H alth District. <br /> Rome owner or licensed agent's signature certifies the.following: "I certio that in the performance of the work for which this <br /> permit is issued, I shall not ggmmploy any person,in such manner as to become subject to workman�compensation laws of California." <br /> Contractor's hiring or sub-cgn"Eracting signatdre certifies the followin : "I certify that in the performance of the work for which- <br /> this permit is issued, I h all employ persons subject to workman's com�iensation laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by , Area Stk 466-6781 <br /> Additional Comments: ' ❑ Lodi 369-3621 <br /> Pit or Grout Inspection.. y 1Zl2 /� Date /-/4 lfj Manteca 823-7104 <br /> Final Inspection by i t_ :2— f Date/-�Q� -�' 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 8Y DATE PERMIT NO. <br /> INFO <br /> � -J 9 � <br /> EH 13-24 REV: 10/82IO/8Z 500, <br /> 14-26 <br /> 1, v A <br />