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APPLICATION FOR PERMIT ? <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT Y3- ()0 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, 3- �00 <br /> Telephone (209) 466-6781 -- 7 <br /> e <br /> PERMIT EXPIRES 1- YEAR FROM GATE 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 Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the an Joaquin Local Healt D'strict. <br /> Job Address CJ U •P/j�0 sj�! � S�ision Name _Cr, <br /> Owner's Name Phone 'p <br /> + f <br /> Contractor's Name - rcelo Phone 7 { ;1 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ELL REPLACEMENT C DESTRUCTION U OQ <br /> PUMP INSTALLATION �' SYSTEM REPAIR +'>•,� OTHER U (!J w <br /> DISTANCE TO NEAREST:. SEPTIC TANK ° SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL � 4Z�. OTHER WELL PITS/SUMPS <br /> L� -4 Q D <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Lr4ottom ❑ Manteca Dia. of Well Excavation ` . <br /> estic/Private, �.Gravel�Pack x Tracy ,Dia. of WeII Casing- ` <br /> Public �j Other Del to <br /> Type of Casing j <br /> Ljlrrigation Approx, L'Eastern Specifications tk <br /> Cathodic Protection Depth 1 <br /> Depth of Grout Seal <br /> Geophysical Type of Grouta>,� y <br /> LJ Other r Surface Seal Installed by <br /> Repair Work DoneE] Type of Pump �� N.P. ' State Work Done <br /> Well Destruction LJ Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') i <br /> r <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION ❑ REPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) O <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: 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 jJ No. & Length of lines Total length/size <br /> FILTER BED II Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS F-1 Depth Size Number <br /> SUMP.S.- _ " - Distance to nearestc�Wel l r_:, . .Foundation ..,_.,_`P.roperty <br /> DISPOSAL PONDS f <br /> F <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 mud call fob 11 required i pections. Complete drawing on reverse Ze. <br /> Signed X c'� Title: �y _­%+ Date: <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted by r[ Area Stk 466-6781 „ 1ile'VA <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection b Date Manteca 823-7104 �� r��83 by of Ji Date ✓ �I Tracy 835-6385 <br /> Final Inspection i <br /> Applicant - Return all copies to: Environmental - ealth Permit/Services 1601 E. Hazelton Ave, P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMYTTEO RECEIVED_ BY DATE PERMIT NO. <br /> INFO A16"1i �Woe <br /> EH 13-24 REV. 10/82 (� 10/82 '500 y <br /> 14-26 <br />