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�n <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (2.09) 466-6781 <br /> 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 Replations of the San Joaquin Local Health District. a <br /> Job Address �„1 _,�(� L,1. Subdivision Name ! 1 <br /> Owner's Name 00: Address S'y�C?S' j�P�,jf. i�rq �:.r. r 1' Phone <br /> Contractor's Name Ayer d4 '' ,y ,� License No. 6s-_ � � Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELLS y WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ( SYSTEM REPAIR ❑ OTHER U <br /> DISTANCE TO NEAREST:,SEPTIC TANK g r SEWER LINES DISPOSAL. FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Js� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation <br /> Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ <br /> Public -, -\ <br /> r2i Other [] Delta <br /> Type'- f,Casing ell � <br /> Ci Irrigation B ! Approx. ❑ Eastern,�"A . �' ��� <br /> ❑ Cathodic Protection Depth Specifications <br /> Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout E 19.`4 ew <br /> FJ Other Surface Seal Installed by- .,^.� <br /> Repair Work Done ❑ Type of Pump 5. H.P, r 2,� State Work Done <br /> Well Destruction ❑1 Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Materia] (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U -REPAIR/,ADDITION ❑ (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/Mfgt­Capacity Method of Disposal <br /> i • ��IJJJ <br /> SEWAGE SYSTEM ❑ Distance to hearest: Well .Foundation Property Line <br /> DESTRUCTION ` <br /> LEACHING LINE ❑ No. & Length of lines ""�_ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well '�.Fourdation Property. Line <br /> SEEPAGE PITS ❑ Depth. Size --Number <br /> SUMPS ❑� Distante to nearest: Well Foundation ~' Property Line 1 <br /> DISPOSAL PONDS ❑ v 1 ' <br /> w <br /> I hereby certify that I have prepared this application and that the work will be done in actordance'with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. "-- i ' <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 workmang compensation laws 6f-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 applicant must call al r ,Pe <br /> s.. Complete drawin reverse side. <br /> Signed X Title: Date: !F/&Ay_ <br /> Application Acce d by �` Q l�C Area / ❑ 5tk 466-6781 <br /> Additional Comments: ] ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date "l G ❑ Manteca 823-7104 <br /> Final-,Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies o: Fn vironmental Health Permit/Services 1601 E. Haze t'add`/ e., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO le-4-113 -1w <br /> V% <br /> EH I3-24 REV. 10/82 10/82 5D0 <br /> 14-26 ti <br />