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APPLICATION FOR PERMIT <br /> # r <br /> SAN JCAQUi'i LOCAL tALiH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 DATEISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E <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 <br /> of the San Joajuin Local Health District. <br /> Job Address . �, '3'T S/_ �r�%� Subdivision Name <br /> J m �;�,� <br /> � �v <br /> Owner's Name Address <br /> Contractor's Name r , ` : License No. �, �,�� _ Phone <br /> oU <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ I w <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ } 1 <br /> SEWER LINES DISPOSAL FLD. E� <br /> DISTANCE AREST: SEPTIC TANK p PITS/SUMPS t1 <br /> £ NOATION AGRICULTURE WELL = OT r <br /> iNTENDED_USE, '' . TYPE L PROBLEM AREA STRUCTION 5 ECIFICATIONS <br /> 1-1 Industrial U Open Bottom Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack cY <br /> of Well Casing f <br /> Putilic Other Oelta Tyne of Casing <br /> Irrigation rox. Q!Easter� i Specifications <br /> LJ Depth # ro <br /> Cathodic Protection Depth—of Grout-Seal <br /> Geophysical ? n) I I� Type of Grout <br /> U Other «11 Surface Seal Installed by <br /> State Work Done . <br /> Re air)Work Done Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Materia)(,top 501) <br />{' <br /> Depth 'Filler Material (Below 50') permdfp• .•�. <br /> i i <br /> TYPE OF_-_SEPTIC,,.WORK: NEW,,I.NSTALLA,TION_L1-.PREP-AIR/.ADDId1:ON}_�- • epta.c=tank-or-seepageP•i-t.aila •ttewiihin 2 01 Teeter—ism -- <br /> available within 2001feet.) <br /> Installation will serve: Residence a Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Water table depth <br /> Character of soil to a depth of 3 feet: ;/-- <br /> r <br /> Type/Mfg , 'Capacity . No. Compartments <br />' SEPTIC TANK Method of Disposal <br /> k PKG. TREATMENT PLT. Type/Mfg i Capacity <br /> y Line <br /> SEWAGE SYSTEM ❑ Distance to nearest: WellFoundation Propert <br /> � '' <br /> DESTRUCTION' <br /> Total. length/size <br /> LEACHING LINE R No. & Length of lines <br /> 444 <br /> FILTER BED Distance to nearest: Well f" Foundation Property Line <br /> SEEPAGE PITS Depth� Size` -Number <br /> SUMPS Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS E <br /> I hereby certify that 1 have prepared this application and+that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. >N of tewhich this <br /> Home owner or licensed agent's signature certifies the following: t certify that in the performanceerisathonwlawsfof California." <br /> permit is issued, I shalL;not.employ.any person in,such manner, as to become sublect to workman§ comp_ <br /> certifies the following: "I certify that in the performance of the work for <br /> Contractor's hiring or Sub-contracting signature which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." „1-, <br /> The applicant muss cal f req i ed inspections. Complete drawing on reverse,side. �,. , �y <br /> Date: / <br /> Signed X f Title: <br /> F R TM ENT USE ONLY ® 14 <br /> Area Stk .466-6781 <br /> Application Accepted by Lodi 7369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> Pit or Grout Inspection b Date <br /> Date L Tracy 835-6385 <br /> r Final Inspection by y201 <br /> Applicant - Return all copies to: Envaronm Health Permit/Services 1661 E.{Hazelton Ave., P.O. 6 2009, St k.; CA 95 <br /> w DATE PERMIT NO. <br /> yFEE BASE MOUNT DUE AMOUNT REMITTED RECEIVED 8Y <br /> 0 <br /> IG/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />