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( APPLICATION FOR PERMIT <br /> SAN JQAQI i^I LOCAL HEALTH a STRICT Q <br /> 1601 E. HAZELTON AVE., STOCKTON, C "7 <br /> Telephone (209) 466-6781 DATE ISSUED 'g <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEp <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 f the San Joa uin Local/,,Health District. / <br /> Job Address } r !f ( Subdivision Name <br /> Owner's Name i 4 T � �— ddress �- k 1'/V Phone <br /> Contractor's Name ir License No. Phone -'�S F32 <br /> W <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _J <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> lJ Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing <br /> 1❑ Public ❑ Other ❑ Delta Type of Casing <br /> Irrigation Approx. ❑ Eastern <br /> ❑ Cathodic Protection Depth Specifications <br /> Depth of Grout Seal <br /> ❑Geophysical <br /> Other Type of Grout <br /> EJ Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done d <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 2(No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence 4/1 Commercial _ Other <br /> Number of living units: _/ Number of bedrooms I Lot size <br /> Character of soil to a depth of 3 fe t: Water table depth <br /> SEPTIC TANK Tfl�_ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Q4 Foundation ZG i Property Line 166 f <br /> DESTRUCTION ❑ <br /> LEACHING LINE No. & Length of lines +� Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 75' Foundation oZr Property Liner <br /> SEEPAGE PITS ❑ Depth t ' _ 10 Number <br /> Size � X <br /> SUMPS Et-' Distance to nearest: Well i Foundation V` 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 workman compensation laws of California." <br /> Contractor's hiring or sub-con ratting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall aemplo persons subject to workman's compensation laws of California." <br /> The applican t 1 for red inspections. Complete drawing on reverse side. <br /> Signed X Title: 6 W� Date: 4iff_10 <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by , Area <br /> ❑ Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection Date Manteca 823-7104 <br /> Final Inspection by DateL7Tracy 835-6385 <br /> Applicant - Return all copi 9 to: Environmental Health Permit/Services 1601 H zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> My <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />