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APPLICATION FOR, PErRi!-, <br /> SAN JOAQH?N LOCAL H=ALT, DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 456-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUE <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 Joaquin Local Health``D�strict. <br /> Job Addrg4 G j�SU Avision Name <br /> gOwnpris <br /> Address yj ' i,on <br /> r c or's Name .- 1 <br /> F <br /> License Na. Phone <br /> TYPE OF WE LL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> Lj SYSTEM REPAIR OTHER <br /> Vv <br /> ' A. PUMP INSTALLATION L- <br /> DISTANCE TO,NEAREST: SEPTIC TANK " !" ! SEWER LINES DISPOSAL FLD. <br /> PROP—LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE- OF WELLI PR03LEM AREA CONSTRUCTION SPECIFICATIONS ¢� . P <br /> ! f <br /> F-1 Industrial U Open Bottom Manteca Dia. of Well Excavation -Sz- <br /> U Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing <br /> (] Public F-1Other Delta r <br /> L• <br /> irrigation Type of Casing <br /> ation i 9 Approx. `EJ <br /> Specifications <br /> Cathodic Protection Depth � t 5 p <br /> Geophysical ' <br /> Depth of Grout!Seal f <br /> ❑Other I Type of Grout. <br /> Surface Seal Installed by <br /> Repair Work Done E] Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth v Filler Material (Below 50') ; <br /> TYPE OF SEPTIC WORK: NEW INSIALLATION REPAIR/ADDITION U*(No septic tank or seepage pit 'permitted if public sewer is m <br /> t f i available within 200 feet.) <br /> Installation will serve: Residences Commercial _ Other i <br /> )!� T <br /> Number of living units: T Number of bedrooms _ Lat size k t r <br /> Character of coil to a depth of 3 feet: Water(teble depth <br /> SEPTIC TANK gi Type/Mfg Capacity � No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg /` Capacity Method of Disposal <br /> SEWAGE SYSTEM ilDistance to nearest: Well + Foundation -= Property Line <br /> DESTRUCTION f--I <br /> LEACHING LINE- No. & Length of lines `3 -*^Total'length/size <br /> FILTER BED rl Distance to nearest: Well Q Q Foundation f jp. Property Line y�� <br /> �`f r <br /> SEEPAGE PITS- Depth . Size Number j <br /> SUMPS } L Distance to nearest: Well Foundation r PropertyLine ; <br /> 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 /> Home owner or licensed agent's signature certifies the following:"'I certify That 'in fife performance of the work for which this <br /> permit is issued, I shall notaemploy any person in such manner as to became subject to workman§ compensation laws of California," <br /> Contractor's hiring or sub-contracting signature certifies the following•'"I1,certify that in the performance of the work for which <br /> this permit is issued, I stall—emp'l'oy"person's"'subject,to,workman's compensation lawsrof California." 1 <br /> The applicant must ca 1/for 11 re uired inspections. Complete drawing on reverse side. <br /> Sig ed X i' Title: Date: 0— � f� <br /> ; <br /> I 0 EPARTMENT USE ONLY L # I <br /> Application Accepted by Area L3 [] Stk 466-6781 <br /> Additional Comments: <br /> i 369-3621 <br /> Pit or Grout Inspection by Date y Manteca 823-7104 <br /> Final Inspection by Date 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 /> FEE. ' BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> EH 13-24 REV.-10/82 s._ .�Mf s" j '" V �l �3 +k�. , -. " a 10182 500 .,+ <br />