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APPLICATION:FOR PERMIT- <br /> SAN <br /> ERMIT-SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA. PERMIT NO. I1--7 <br /> 1 Telephone (209) 466-6181 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 <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 Regulatio of he San aquin Local Health District. <br /> Job Address ��� Subd'vision Name- -, <br /> Af <br /> Owner's Name Address <br /> Contractor's Name <br /> License No. + Phon <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 FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� _ <br /> 1-1Industrial <br /> ❑Open Bottom ❑Manteca f Dia of.Well Excavation s '' <br /> ;&Zmestic/Private ----❑Gravel"Pack ` '❑Tracy ..r Oia. of Well-Casing .z� .. <br /> ❑ Public ❑Other ❑ Delta Type of Casing <br /> irrigation Approx. Eastern �.r- i <br /> U ❑ Specifications <br /> ❑Cathodic Protection Depth a Depth of Grout Seal ` <br /> ❑Geophysical Type of Grout } <br /> Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H,P. State Work Done `- <br /> Well Destruction ❑ Well Diameter Sealing Material (top30'}- -°-�- <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit <br /> avapermitted <br /> ifpublic <br /> ilable within 200fset ew) is <br /> Installation will serve: Residence _ Commercial � Other <br /> Number of living units: Number of bedrooms &L-ot-sizep-�,­ <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. E] Type/Mfg Capacity '�l Method of Disposal <br /> SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation { - Property Line <br /> DESTRUCTION <br /> LEACHING LINE ❑ 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 /> f DISPOSAL PONDS ❑ <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 /> Nome owner or licensed agent's signature certifies the following. "I certify that in the performance of the work for which this <br /> h 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 hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> f this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> E The applicant ust call for l required inspections. Complete drawing on reverse side. /O/�J�� <br /> Title: _ ltrn-e-�� Date: <br /> Signed X - <br /> FOR ARM T USE QALY C3 <br /> ' L� ❑ <br /> Application Accepted by Area Stk 466-6781- <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspectio y Date ❑ Manteca 823-7104 <br /> Final Inspection byUA Date 4' Ey'a ❑ Tracy 835-63B5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> !4i <br /> AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> /V <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 _ .. <br /> 14-26 f <br />