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APPLICATION FOR,PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT �§ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 p <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - <br /> C'Z mplete 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 made-in compliance with San Joaq in County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rul Regulatio f tS Joaquin Lwal/ Eaal i rict, k <br /> Job Addre [qq✓✓ K) .j is/ion}Name <br /> Owner's Name AM 0 L Q R:T-6 Address Phone <br /> Contractor's NameC.LA(%K WC-L( License No. Phone �/l�J_�'" <br /> I <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTIONS <br /> PUMP INSTALLATIONSYSTEM REPAIR U OTHER Ute`, <br /> DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> 0mestic/Private ravel Pack Tra Dia. of Well Casing <br /> 0 Public F1 Other elta Type of Casing <br /> I i Irrigation Approx. ❑ Eastern <br /> Depth Specifications r <br /> Cathodic Protection Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> LJ Other <br /> .� Surface Seal Installed by � C <br /> Repair Work Done ❑ Type of Pump State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501) A <br /> r� - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION F1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <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 E] Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. F] Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance.to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> I SEEPAGE PITS ❑ Depth _ Size _ Number <br /> SUMPS Distance to nearest: Weil Foundation Property Line <br /> DISPOSAL PONDS C� <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 workmanK compensation laws of California." <br /> Contractor's hiring or sub- nt cting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit i lissed, 11 a loy rs s sub ct to workman's compensation laws of California." <br /> The appli. n m1 f 1 i ed i Complete dr w' on �vers <br /> d _// `` <br /> Signed X Title: ��" 44 Date: 'Y <br /> R DEPARTME6iP USE ON d� Stk 466-6781 / <br /> Application Accepted by Area �)Q <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by to \ _ U Manteca 823-7104 <br /> Final Inspection by e � --���'`� <br /> Tracy 835-6385 <br /> Applicant - Retufn all copies to: Environmental Health Permit/Services 1601 E. Hazeltor Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 �LJ <br /> 14-26 <br />