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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 —tObS <br /> Telephone (209) 466-6781 11 <br /> PERMIT EXPIRES !-YEAR FROM DATE ISSUED 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 Joaqu.n County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Ap lations of the San Joaquin.Local Heklyrict. I1 <br /> Job Address SI I <br /> 8 ubdivision Name i <br /> H Owner's Name Address Phone r I� <br /> 1 Y Contractor's Name+ E License No, p4q _ Phone 'gs . <br /> TYPE OF WELL/PUMP WORK: w NEW WELL Q WELL-REPLACEMENT Q ' DESTRUCTION iw <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U <br /> DISTANCE TO_NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED JSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation I� <br /> Domestic/Private 0 Gravel Pack � Tracy_ _ Dia, of Well Casing <br /> Public .�. ,.. r_ :. . <br /> I -Other [ Del to n g <br /> l <br /> Irrigation i g f Type of Casing I <br /> V g t Approx. Eastern s <br /> ❑ Cathodic Protection Depth Specifications R <br /> 1-1 Geophysical Depth of Grout Seal I� <br /> Type of Grout I� <br /> Lj other <br /> Surface Seal Installed by <br /> Repair Work Done FJ -Type of Pump H.P. State Work Done I� <br /> Well DestructionU Well,,Diameter Sea 1ing'Material"(topx60',) s <br /> !Depth- ;Filler Material (Below 50') j <br /> 4 ,y <br /> TYPE OF SEPTIC WORK:! NEW INSTALLATION _,REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> !available within 200 feet.) <br /> Installation will serve: sidenceCommercial _ Other ,e�q <br /> 1� Number of living units: YrNuof bedrooms Lot size <br /> 4 Character of soil to a depth of 3 feet: t Water table depth III` <br /> SEPTIC TANKType/Mfg P Capacity No.. Compartments <br /> PKG. TREATMENT PLT. 0 Type/Mfg Capacity ! Method of Disposal jM <br /> SEWAGE SYSTEM Di stance to nearest: Well .{ �Found_ation__ i `Property Line IN <br /> DESTRUCTION a L�: 1 F O <br /> LEACHING LINE No. & Length of lines y� 'X 'Z Total length/size!/ �E <br /> FILTER BED L] Distance to nearest: Well Foundation Property Line u <br /> SEEPAGE PITS [jY Depth Size _ Number I� <br /> SUMPS Distance to nearest: Well , Foundation�j _ Property Line s <br /> DISPOSAL PONDS 4 i we, <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 signatur_e_cer_t.i_fies 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 laws0f California." <br /> tractor's hiring sub-contracti signature certifies the fol lowing:""I'Cert"ify�that in the performance of the work for which <br /> this t is issue shall emplo ers ject to workman's compensation law's of California." <br /> The applican c 11 f d 'n cti ns. Complete dr wing'on,a erse si <br /> Si ed X Title: } �� Date: ' r <br /> x ,R FORBU TMENT ION Y <br /> Application Accepted bye m Area — k 46b-6781 <br /> Additional Comments: I Lodi 369-3621 <br /> Pit or Grout inspection by d'= Date A ] Manteca 823-7144 <br /> Final Inspection by is Date ( Tracy 635-6385 <br /> Applicant - Return all cop" sEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.( CA 95201 <br /> FEE BASE I AMOUNT ZDUET AMOUNT REMITTED:" #RECEIVED BY DATE PERMIT NQ! <br /> INFO <br /> 933 i oes <br /> EH 13-24 REV, 10/82 10/82 500 <br /> 14-26 I' <br />