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x <br /> i <br /> APPLICATION FOR.PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE_ STOCKTON, -CA PERMIT NO, R3 <br /> Telephone (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 y <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 t e San J1oaqu. Local Health District. <br /> Job Address 9®9 !l9 (�1 t "_ vision Name <br /> ' a QS23�ione $ 7—30-7O <br /> Owner's Name a Address 8 r <br /> Contractor's Name r x License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F-1 DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR 17 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 /> Industrial U Open Bottom Manteca Dia. of Well Excavation i <br /> U Domestic/Private F-1 Gravel Pack Tracy Dia. of Well Casing <br /> Public- - ri Other [] Delta Type of Casing <br /> F-11 Irrigation Approx. [} Eastern Specifications w <br /> Cathodic Protection Depth rQ <br /> Depth of Grout Seal Q , <br /> "1-1 Geophysical y "Type of Grout , <br /> U Other - Surface Seal Installed by ' <br /> Repair Work Done [JType of Pump H.P. State Work Done C, <br /> Well Destruction U Well Diameter Sealing 'Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEWIINSTALLATION �� R ADOITI X (No septic tank or seepage pit permitted ifpublic <br /> n 200 fsewe) is <br /> ailable withi <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Lot size e Q�teS <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK [_j Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line "5 <br /> DESTRUCTION <br /> LEACHING LINE X, No. &Length of lines 7C CIC) Total length/size /0 0 1 <br /> FILTER BED ❑ Distance to nearest: Well - Foundation Property Line <br /> SEEPAGE PITS K Depth Size Number <br /> SUMPS L—I Distance to nearest: Well Foundation 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 Joaquinhcounty <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 workman compensation -laws of California." <br /> Contractor's hi ing or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is sued, I shall employ per ns subject to workman's compensation laws of California." <br /> The appli an st call f a r ui d spections, Complete dra ing on reverse side. 7 2 <br /> Signed X <br /> Title: Date: _ <br /> P ENT USE Y Stk 466-6781 <br /> 4 <br /> Replication ccepted by /A <br /> Lodi 369-3621 <br /> Additional Comments: � <br /> Pit or Grout Inspection by <br /> Date V Manteca 823-7104 <br /> Final Inspection by ✓�� <br /> Date .�=�6"�.3 � 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 RyEECEIVED BY � DATE p-� PERMIT NO. <br /> INFO <br /> L �� 47 73_Z. 2 <br /> L� f� 10/82 50C <br /> (� <br /> EH REV. 10/82 �(. <br /> 14-26 eC <br /> —2-(+3 1 <br />