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APPLICATION FOR PERMIT <br /> SAN JOAQU'iI1 LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STCCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE 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,Regu.lations of the San Joaquin LofaI Health District, <br /> Job Address % s? �p M d C d/ ° <br /> Subdivision Name �1 gw <br /> I <br /> Owner's Name Address _ �'aMSTe[�,< j_,_ Phone.��1v� <br /> 1 Contractor's Name [� �r =cense No. d Phone <br /> I TYPE OF WELL/PUMP WORK. NEW T,yNEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> " PUMP INSTALLATION '"SYSTEM REPAIR ❑ OTHER ❑ ► <br /> DISTANCE TO NEAREST: SEPTIC TANKQ�— SEWER LINES DISPOSAL FLD. � PROP. LINE <br /> FOUNDATION <br /> AGRICULTURE WELLOTHER WELL <br /> WELL (,042 PITS/SUMPS <br /> INTENDED USE _TYPE OF WEL4 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industria] U Open Bottom Manteca <br /> ❑ ! Dia, of Well Excavation <br /> Domestic/Private <br /> J� a Gravel Pack Tracy Dia, of Well Casing !/ <br /> ❑ <br /> Public i [j Other Delta <br /> 71,1 rrigation + Type of Casing L <br /> Approx. Eastern <br /> Cathodic Protection Depth Specifications <br /> ❑Geophysical D pth of Grout Seal 1 <br /> Othere of Grout \ <br /> Surface Seal Installed by AZ­ <br /> I <br /> Repair Work Dorie.�R Typeiof)Pump H.P. State Work Done <br /> Well Destruction U'> Well'Di��meer Sealing Material (top 501) [ <br /> } Depth Filler Material (Below 50') \4 <br /> TYPEOF SEPTIC WORK: NEW IN=STALLATION ❑ REPAIR/,ADDITION U (No septic tank or seepage pitpermitted if public sewer is ~ <br /> Instal Tation'wiII serve: ;Residence _ Commercial Other available within 200 feet,) <br /> .Number of 1i.ving_pnits: _i. Number of bedrooms Lot Size O <br /> Character'of''soil'to a depth of 3 feet: 1 Water table depth 1 <br /> T <br /> SEPIC TANK T t <br /> _ __ ❑ ype/Mfg � Capacity No. Compartments <br /> PKG.Y TREATMENT PLT. ❑ Type/Mfg , Capacity+ �. g Method of Disposal <br /> SEWAGE 'SYSTEM I Distance to nearest: Well Foundations i Property Line <br /> DESTRUCTION C1 ¢ Q <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ,Well Foundation Property Line { <br /> SEEPAGE PITS Depth Size Number f <br /> SUMPS Distance to nearest: Well Foundation Property Line j <br /> L_ <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance witht,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 q <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." I' <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." E <br /> The applicant must cal or al q Sp plete draw g on reverse side. <br /> Signed X Title: Date: OAF <br /> [ RPRRT USE ONLY Area GZ <br /> Application Accept by Stk 466-678 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies Environmertal Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE RFRMIT NO. I <br /> INFO U <br /> Y3 y3 �13 a� b 30 cs3—lain ! <br /> EH 13-24 REV. 10/82 10/$2 .500 <br /> 14-26 <br /> _ ill- <br />