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4 <br /> ' A <br /> APPLICATION FOR PERMIT <br /> i <br /> $A.N JOAQUiI; LOCA! HEALTH DISTRICT �_ � �� <br /> 1601 E. HAZELTON AVE., STOCKTON, 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 corn liance with San Joaquin Count Ord�ance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Re ula ions of th San uin L al Health District. f <br /> 7 I <br /> Job Address , � ubd' a <br /> Owner's Name p Address �6 771V a��r1,&.r Oct. Phone _3� p PC-- <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP 14ORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U i <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 G� <br /> J Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing <br /> Public 11 Other Delta <br /> irrigation Type of Casing i <br /> F, <br /> g Depthx, � Eastern Specifications � <br /> ❑ Cathodic Protection p <br /> Depth of Grout Seal <br /> Geophysical <br /> Other Type of Grout t <br /> i Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump i �H.P, State Work Done ! <br /> Well Destruction Well Diameter 3eaiing Material (top 50') _ -- <br /> �� (,(J Depth /Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L_� 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 Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <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 /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Ci <br /> I hereby certify that I 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. <br /> Home owner or licensed agent's signature certifies the fallowing: "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 workmant compensation laws of California." <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." 4 <br /> The applicant t call for all required inspections. Complete drawing on reverse side. <br /> Signed X ( Title: Date: -3 <br /> FOR ARTMENT USE ONLY <br /> Application Accepted by Area l Z ❑ Stk 466-6781 <br /> Additional Comments: 777�� Lodi 369-3621 <br /> q <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection byDate T � Tracy 835-6385 <br /> a <br /> Applicant - Return all copies to: Envir m ntaI Hea th Permit/Services 1601 E. Hazelton AV P.Q. Box 2009, Stk„ CA 95201 <br /> FEE BASE AM UNT DUE AMOUNT REMITTED R E VED BY ATE PERMIT N0, <br /> INFO <br /> 6a d <br /> EH 13-24 REV. 10182 1 _ 10182 500 <br /> 14-26 ��+�v <br />