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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE­ STOCKTON, CA PERMIT NO. - <br /> Telephone (209) 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 Regulations of. the San Joao,,uin Local Health District, <br /> Job Address Subdivision Name <br /> Owner's Name Address .S30-5- e7fr,F/I 1.vq_� ���� Phone <br /> l7k <br /> Contractor's Name 0A K, J(4-f All, 4 ,2 License No. --,2"7 Phone W <br /> e , <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ( SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:,SEPTIC TANK gs, SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR03LEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing 6 `� <br /> ❑ Public �jOther ❑ Delta <br /> Type..o f-Casing <br /> V Irrigation 9,0.4,r Approx, ❑ Eastern--�— — — •catA0 <br /> ❑Cathodic Protection Depth Specific �-•y- <br /> Depth of Grout Seal <br /> ❑Geophysical Type of Grout � '/`fr'y <br /> ❑Other Surface Seal Installed by -e <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 L1 .REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is . <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Comme cial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Char act, <br /> r'of soil to a depth of 3 feet: =� -- Water table depth <br /> SEPTIC TANK ",, Type/Mfg 'A Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ TypeyMfg P- Capdcity Method of Disposal <br /> SEWAGE SYSTEMDistance to nearest: Well ­ �Foundation Property Line <br /> DESTRUCTION C:] <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ., <br /> FILTER BED ❑ Distance to nearest: Well "-..Foundation Property Line j <br /> i <br /> SEEPAGE PITS ❑ Depth Size "-�--Number <br /> SUMPS Distance to nearest: Well 'Foundation Property Line { <br /> DISPOSAL PONDS ❑ v <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 wo'rkjfor which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman§ 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 spe s.. Complete drawin reverse side. �4~ <br /> Signed X Title: Date: <br /> D PA ENT USE/�� <br /> Application Acce d by Area ❑ Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by , Date I ❑ Manteca 823-7104 <br /> Final Inspection by . - -lu Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies o: Ervironmenta Health Permit/Services 1601 E. Haze tc(ve., P.D. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ����// DATE PERMIT NO. <br /> INFO �11 %$ L4 <br /> EH 13-24 REV, 10182 10/82 500 <br /> 14-26 'k <br />