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+� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT: <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephore (209) 465-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 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,t he Rules }}and Regulations of the San Joaquin "cal th District,Job Address ! ��f� .c � � <br /> Owner's Name F "�;(1.f `i, a. Address Phone3�� �'�-� <br /> Contractor's Name J!tL . lsixgnse No. -1 __ Phone77C,15, <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE Q <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial F'Open Bottom Manteca Dia, of Well Excavation j <br /> LWTIZmestic/Private Gravel Pack Tracy Dia. of Well Casing - <br /> Public G Other Delta Type of Casing --W- <br /> V Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth Depth of Grout Seal j <br /> Geophysical Type of Grout a<— <br /> Other � f Surface Seal Installed by <br /> t <br /> I' Repair Work Done G Type of Pump Ca W H.P. 1 State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (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 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity. Method of Disposal <br /> SEWAGE SYSTEM tt--1 Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION u <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> t- �1.i.- SUMPS ...Distance to nearest:.. Well — Foundation, Property Line <br /> DISPOSAL PONDS Cj <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> p 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 California."s <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman <br /> 5 compensation laws of Californ <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 must call for all required inspections. Complete drawing on reverse side, g <br /> Signed X am Title: n(-,�-,.-g5o&13 Date os <br /> r <br /> I Application Accepted by FOR DEPARTMENT USE ONLYArea Stk 466-6781 <br /> Additional Comments: a Lodi 369-3621 <br /> Pit or Grout lnspectian b Da a Manteca 823-7104 <br /> Z4 Final Inspection by Date '49 Tracy 835-6385 <br /> j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 <br /> r FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO ` ` <br /> EH 13-24 REV. 10/82 10/82 5OC <br /> 14-26 <br />