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APPLICATION FOR PERMIT <br /> M E"IN E P, V11 C E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, 05 7 <br /> C o;n I �1 1 o r,5,LiC� -,�2 Telephone (209) 466-6781 DATE ISSUEDII <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 Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the an doa ocal Health District. RW " Ir <br /> -1 ;u ,i., . 0" 7 ,**,? <br /> Job Address 12 Name <br /> A <br /> Owner's Name Address 7 Phone <br /> VVi -- <br /> JU4 Phone <br /> Contractor's Name 1.4AU.Pcense No, <br /> TYPE OF WELL/PUMP WORK: NEW WELL � WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION L] SYSTEM REPAIR OTHER <br /> DISTANCE TO' NEAREST: SEPTIC,.TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> FlIndustrial f—lopen Bottom Manteca Did. of Well Excavation <br /> Domestic/Private F-]Gravel Pack Tracy Did. of well Casing <br /> Public F-1OtherE] Delta Type of Casing <br /> irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done FJ Type of Pump H.P. State Work Done <br /> Well Destruction FI Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION J (No septic tank orls'eepage 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 bedroom� Lot:size 2 3_4 <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 c Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation � Property Line <br /> SEEPAGE PITS X 7-1 <br /> Depth 40 Size Number <br /> 06-7— <br /> SUMPS j F-1 Distance to nearest: Well Foundation s Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San,Jo6quin 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 workmancompensation 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 appli;a�n�A�sll for all reo2ire d/inspec ns. Complete d <br /> Signed X Title: Date: <br /> R ART T USE NLY <br /> Area Stk (�466-6781Application Accepted by 14 <br /> Additional Comments: E] Lodi 369-3621 <br /> Pit or Grout Inspection by Date <br /> —e3 Manteca 823-7104 <br /> Final Inspection by Date 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 BY DATE PERMIT NO. <br /> FEE <br /> ifs —X-* _ <br /> C <br /> EH 13-24 REV. 10182 f2" C,,,,� 10/82 500 <br /> 14-26 <br />