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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 'v�1 <br /> Telephone (209) 466-6781 DATE ISSUED 3 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> s <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 I <br /> and the Rules and Regulations of the San Joaquin Local Health District. i <br /> Job Address <br /> Subdivision Name ' <br /> Owner's Name <br /> ' Address- /w"� oY Phone <br /> Contractor's Na <br /> ` License No. Z Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL [} WELL REPLACEMENT j] DESTRUCTION <br /> _ t <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL D. PROP, LINE <br /> Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IJ Industrial U Open Bottom E]Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public Other Delta Type of Casing <br /> V Irrigation Approx. E] Eastern Specifications <br /> F-1Cathodic Protection Depth ,,T.Depth of Grout Seal <br /> 1 -<Type of Grout <br /> Geophysical — <br /> E L J Other Surface Seal Installed by <br /> Repo,r Work Done FJ Type of Pump H.P. 4--St-ate Work Done - <br /> Well ;Destruction ❑ Well Diameter Sealing aterial (tap 50') <br /> Depth Fill era Material (Below 50')-. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION (No septic tank or seepage`Pjavaelableewithid if nu200cfeete} is <br /> Installation will serve: Residence Commercial _ Other Y <br /> Number of living units. _ — Number of+b d ooms _ Lot size <br /> CharacterTof-soil=to-a ` epth-o..;3 feet: ;L <br /> Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> Capacity Method of Disposal <br /> PKG: TREATMENT PLT. E] Type/Mfg , <br /> JProperty Line <br /> SEWAGE SYSTEM Q Distance to nearest':,,' Well //}f� Foundation i <br /> 'DESTRUCTION <br /> `LEACHING LINE LJ ' No. & Length of lines 'p� y( i Total length/size <br /> Property Line f <br /> ,FILTER BED ��, Distance to nearest: .Weld Foundation P <br /> n r Size �� Number' <br /> SEEPAGE PITS Depth q(� y Property Line r <br /> SUMPS �� Distance to nearest: Welles/,S Foundation �,S P y —'S' �I <br /> �4DISPOSRL PONDS <br /> . f <br /> u I hereby certify that I have prepared this application and that the work,-will he done in �accor-dance_withrSan-Roaq n.-county�,� <br /> +� ordinances, state laws, and rules and regulations of the San Joaquin Local y fhl tin the pe v, <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the .performance of the work :fay^ which this <br /> permit is issued, I shall not employ any person in such manner as to become subje £ to workman compensation of the-- California." <br /> Contractor's hiring or sub-cont signature certifies the fallowing "Iycertify-that in the.performan work for which <br /> thus permit is issued, I shall employ persons subject to workman's compensation laws of,Cali�for�naT" �1� <br /> ' The app <br /> lican must cal fa all required inspections. Complete drawing��� onreverse side:j� <br /> a <.-. e: <br /> Signed X <br /> # c FO�T�MENTUSE ONLYtkAppli tion Rccepted by I Area _ � Lodi 369-3621 <br /> e Additional Comments: - <br /> Date � � Manteca 823-7104 <br /> Pit or Grout Inspection Tracy 835-6385 <br /> $ Final Inspection by <br /> E Date <br /> _ Applicant - Return all copies Ao,: Envir nmertal Health Permit/Services 16 E."a .lon Ave., P.O. Box 2009, Stk., CA 95201 <br /> ` FEE AMOUNT DUE <br /> NFO �_!AIEAMOUNT REMITTED RECEIVED BYDATE PERMIT NO. <br /> I5 �{ a5 �3 <br /> t 10/82.'-500 <br /> EH 13-24 REV. 10/82 <br /> �e <br /> 14-26 <br />