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APPLICATION FOR PERMIT <br /> f- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 DATE ISSUED { l <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 <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> f and the Rules and Re ulations h�of} the S n Joaquin,Local Health District. <br /> Job Address /V. Qf�YI Subdivi/s ion Name <br /> Owner's Name Address C! gO .., Phone <br /> Contractor's Nam 7 License No. ��v7�r �la` Phone �� <br /> WEE <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial Open Bottom' ``[] Manteca Dia. of Well Excavation <br /> Domestic/Private I <br /> Gravel'Pack (]iTracy-,_„ Dia. of Well Casing : <br /> Public Cj Other Delta <br /> Type of Casing <br /> U Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> jJ Other <br /> Surface Seal.Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done'*; �l <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) 6` <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITIONw (No.septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence X Commercial _ Other :..z 1 <br /> -Number of living..units: Number of b drooms Lot size <br /> Character of soil to a depth of 3'feet: cr•-s = ,f Water table depth <br /> SEPTIC TANK Ej Type/Mfg 4 Capacity No. Compartments <br /> ' PKG. TREATMENT PLT. ❑ Type/Mfg Capacity -�,^Method of Disposal <br /> Distance to nearest:.,i-Well- Foundationt Property Line i <br /> J 4 r Ir r <br /> fes' <br /> LEACHING LINE U No. & Length of lines Total length/size 1 <br /> w <br /> FILTER BED Distance to nearest' tiWell /Foundation Property Line , <br /> SEEPAGE PITS Ek<- Depth Size{ Number <br /> SUMPS U Distance to nearest, WEU /D-D Foundation /o Property Line S <br /> DISPOSAL PONDS . f� <br /> I hereby certify that I have prepared this application and that_the-wor`k•will_be-done in-accordance with'San Joaquin county <br /> ordinances" state laws, and rules and regulations�of the-S�oaquin Local,Health District. <br /> Home owner or licensed agent's signature certifies :the'fo7lowing: 11-certify that in the performance of the work for ,which this <br /> permit is issued, 1 shall not employ any person`in such manner as to become subject to workman1s 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." <br /> The applic t must cell f r all required inspection's".` Complete drawing on'r erse side. ry <br /> `T ^� p <br /> Signed X J'--P - Title: _ ' a� �� Date: � aC -00C <br /> FOR DEPNT U ONLY <br /> ARTM <br /> Application Accepted by ' Area C7f �" q" ❑ Stk 466-6781 <br /> Additional Comments: w a { Lodi 369-3621 <br /> + Pit or Grout Inspecticrtx,:Date Manteca 823-7104 <br /> Final Inspection by, AM te . 0 Tracy 835-6385. <br /> Applicant - Return all cop; iii: Env ronmental Health Permit/Services 101 FE: Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. f' <br /> 1 INFO . <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />