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4 ") r 1- <br /> ) b <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT n ' <br /> 160I E. HAZELTON A4'E., STOCKTON, CA PERMIT NO.^ 7 <br /> Telephone (209; 466-6781 <br /> - <br /> DATE !sSUED [ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �[T <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 welllpuntp <br /> and the Rules and Regulations of the San Joanuin Local H alth District. <br /> Job Address J•5 �c z 1/lQ — i <br /> Owner's Names — ��'p _ Address - oal&nPhone <br /> Contractor's Name , r License No. 4 2 - Phone <br /> ;r <br /> TYPE• L�/PUMP WORK: NEW WELL C WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION IJP SYSTEM REPAIR OTHER �J <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 Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack Tracy Dia, of Well Casing1 <br /> Public ❑ Other Delta <br /> Irri ation Type of Casing <br /> L 9 Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> LI Geophysical <br /> [7j Other Type of Grout <br /> c Surface Seal Installed by — <br /> Repair Work Done Type of Pump H.P. -.W- State Work Done j ,gyp Z, <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [71 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> _ <br /> Installation will serve: Residence Commercial Other available within 200 feet.) <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 LJ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE ;T 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 L Distance to nearest: Well Foundation Property Line <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 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 workmanIs 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 /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant F st call for,�l]Lquired inspections. Complete drawayig or reverse side. <br /> Signed X Title: r 1 t' .%r Date: <br /> 0 DEPARTMENT USE ONLY / <br /> Application Accepted by Area d ( [] Stk 466-6781 <br /> Additional Comments: _ Lodi 369-3621 <br /> Fit or Grout Inspection 4 Date ❑ Manteca 823-7104 <br /> Final Inspection by Date 1plt,��ve. Tracy 835-6385 <br /> 19 Applicant - Return all copies to: Eoviro mental Health Permit/Services 1601 Haz , P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO 4 <br /> �' - 33 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />