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t <br /> \ APPLICATION FOR PERMIT <br /> \ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �' l <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 Joaquin Local Health District. <br /> Job Address peA -rrA<-ZSubdivision Name <br /> Owner's Name RAV4 ZA(,AR15 Address Phone <br /> Contractor's Name ,,=vL�L License No. Phone 3 V`&A3 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION F-] SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial U Open Bottom F-I Manteca Dia. of Well Excavation o <br /> _ ----�_� Domestic/PrivateGravel._.Pack �] Tracy Dia. of Well Casing <br /> -Public Otherr Delta Type of Casing <br /> t j;ia rigation - - Approx. �] Eastern Specifications <br /> •Cathodic''Protection, Depth <br /> u;�c� Depth of Grout Seal ; <br /> L:J Geophysi.cal Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done Typ2 Of Pilmp �; <'• State Work Done <br /> Well Destruction,[„1_`LWell Diameter; _;Sealing Material (top`50 ) - <br /> - iFiller,Material (Below 50') <br /> - .AeVt►r <br /> TYPE OF SEPtIC WORK: NEW INSTALLATION U` ;REP&P/ADbiT-ION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> __.._._ <br /> ayOlable within 200 feet.) <br /> Installation will serve: °R'esidence � `Commercial/, Other 4� <br /> Number of living units: �_ Number of bedrooms.' Lot size <br /> Character of soil to a depth of 3 feet: /)6 73 Water table depth <br /> $EPTIC.TANK Type/Mfg Capacity c%t_ No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg + -- T--CapaCity Method of Disposal <br /> ` SEWAGE SYSTEM; Distance to nearest:: Wdif Foundation Property Line <br /> DESTRUCTION <br /> INE �. ' �f No. & Length 'of lines Total length/s"ize <br /> T <br /> LEACHING h <br /> FILTER BE 6 [] Distance to nearest: -Well T Foundation Property Line -E�= <br /> SEEPAGE PITS ( j• Depth Size Number <br /> SUMPS Distance to nearest: •Wel} - - Foundation Property iDe.._. <br /> DISPOSAL PIDNDS C <br /> hereby certify'that I have prepared this application and that the Oo,rk w#}1 be Bette in aecordalnce with San Joaquin county <br /> ordinance§, stall@ laws, and rules and regulations of the San Joaquin Local Health Distri t. <br /> Home owner', or licensed agent's signature certifies the following: "I certify that in the rformance of the work for which this <br /> permit is ,issued, I shall not employ any person in such manner as to become subject to workmans compensation laws of California.' <br /> dontractor''s hiring Qr,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 for. required inspections. Complete drawing on reverse <br /> side. <br /> Signed X Title: Date: <br /> ? FO§#ERARTMENT USE ONLY ® ❑ <br /> Application Accepted by - ` Area Btk 466-6781 <br /> Additional Comments:, [� Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copiies to: Envi ronmfrtfai 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 /> _ ..INFO _.... _ <br /> ;.. <br /> 10182 500.--- <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />