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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO, Iq�O <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete it 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 /> t 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 <br /> the San ]oaquin Local Health District, <br /> Job Address _ / BriAjjNj1 ,* /0 Subdivision Name <br /> Owner's Name _ Address g� 4 SPhone <br /> .- J <br /> Contractor's Name - License No. '� _ Phone ��//tel�j ^^•�� <br /> W <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 UI5POSAL FLO. PROP. LINE (� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rW/� <br /> INTENDED USE TY?E OF WELL jPROBLEM AREA CONSTRUCTION SPECIFICATIONS V ' <br /> J Industrial U Open Bottom r Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack 'Tracy R Dia. of Well Casing <br /> Public Other ��' Delta Type of•,Casing <br /> L Irrigation Approx. Eastern t` '"`" <br /> V Oepth t, Specifications <br /> FICathodic Protection Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout <br /> U Other <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION }_�[� REPAIR/ADDITION {No t'eptic 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 TANKType/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 No. & Length of lines - T Total length/size, ' <br /> FILTER BED Distance to nearest: Well 1`0�1 Foundation �p F� Property LineZi ' <br /> SEEPAGE PITS Depth Size f/X&X/d Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C� ' <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 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 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 /> „y this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant m�ust�c�aJ] f9,Pall required inspections. Complete drawing on reverse side. / <br /> T /,! � - Title: Date: / G <br /> Signed X , ' <br /> FOR-DEPMENT SE ONLY <br /> Application Accepted by Area _ Stk 466-6781 <br /> ' Additional Comments: E] Lodi. 369-3621 <br /> Pit or Grout Inspection Date 0-Manteca 823-7104 <br /> Final Inspection by _ t Date 31�1-� L7 Tracy 835-6385 <br /> Applicant - Return all copies t : Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> rFED EE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERM�NO. <br /> NFO <br /> ` y <br /> - -EH 13-24 REV. 10/82 10/82 500 <br /> - - <br /> 14-26 <br />