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APPLICATION FOR PERNiiIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 26CI E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (204} 465-6781 <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 Regulations of the San Joaquin Local Heal h District. <br /> Job Address 6Z 62%Of ALOWSubdivision Name Q e <br /> Owner's Name r/► Address ��� .- [,{,f IeA /�p�'� Phone l <br /> Con'tractor's Name yx <br /> f ' <br /> cense No, ) Phone <br /> r"L `A!ik L <br /> r' <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION j <br /> PUMP INSTALLATION ( SYSTEM REPAIR LJ OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK lli(a 4 SEWER LINES ® DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Open Bottom Manteca .y f% <br /> ❑ Dia. of Well Excavation <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ft <br /> ❑ Public ❑ Other ❑ Delta <br /> Irrigation Type of CasingYo <br /> Approx. ❑ Eastern <br /> ❑ Cathodic Protection Depth Specifications <br /> 1­1 Geophysical .- t_ Depth of Grout Seal t3 e <br /> ❑Other -Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done rT a' -- c <br /> [J Type of Pump - H,p, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> 3 <br /> Depth `�,,. _ _filler MateTial�'(Below 50f) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ' REPAiR 4DOITIO U ( p seepage pit permitted if public sewer is <br /> LI / (No'se tic tank or see a e <br /> �, available within 200 feet.) <br /> Installation will serve: Residence _ Commercial' ' Other p <br /> Number of living units:` '" `�NuirUr af�bedrooms4- »*°Cot size <br /> Character-of soil to a depth of 3 feet: <br /> f Water table depth 4 <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> !f <br /> PKG. TREATMENT PLT. Type/Mfg❑ Capacity Method of Disposal � <br /> ? SEWAGE SYSTEM Distance to nearest: Well Foundationk Property Line M <br /> DESTRUCTION ❑ <br /> k LEACHING LINE Lf No. & Length of lines e Total length/size <br /> FILTER BED Distance to nearest: Well Foundations Property Line <br /> `r <br /> SEEPAGE PITS ❑ Depth Size ' Number + <br /> SUMPS ❑ Distance to nearest: Well Foundation, Property Line <br /> DISPOSAL PONDS ❑ <br /> ,<-I--hereby certify that I have prepared this applicationand,t <br /> hat.the work will be done in accordance awhtan"Jo in-county <br /> ordinances; state laws."-&M <br /> 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,mannerr,as to become subject to workman5 compensation laws of California." <br /> Contractor's hiring or sub-contracting sig6ature 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." a <br /> The applicant must 1 r re &tions. Complete draSigned X Title: tq•$l� Date:�E LY , <br /> Application Acc ted by Area 5tH 466-6781 <br /> AD Additional Comments: ❑ Lodi 369-3621 <br /> --Pit or Grout Inspection by Date �- - �j ❑ Manteca 823-7104 <br /> Final Inspection by Date Z ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: - Envirormental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., Cly 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. # <br /> INFO <br /> EH 13-24 REV. 10/82 '4 to 10/82 500 <br /> 14-26 <br /> i <br />