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} APPLICATION FOR PERM!T 1w /I <br /> S�ZA4 <br /> SAN JOAQUiN LOCAL HEALTH 'DISTRICT �L'� fuKp <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. !�{JQ <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 Reg u1 tions of the an Joaquin�ALo�call LHeealth District. <br /> Job Address �°1�-�, M iq Mt"� 7 Subdivision Name <br /> Owner's Name Address 06 Phone <br /> Contractor's Name ense No. Phone`�� <br /> TYPE OF WELL/PUMP WORK: NEW WELL WILL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I® I DISPOSAL FLO. 1,436­1' _ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL —� PITS/SUMPS <br /> INTENDED USE TYP OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i J Industrial PrOpen Bottom F�Manteca Dia. of Well Excavation <br /> C?<.-estic/Private F-1 Gravel Pack Tracy Dia. of Well Casing If <br /> 1 Public [-1 Other Delta Type of Casing <br /> , Irrigation Approx. Eastern <br /> ❑Cathodic Protection <br /> Depth Specifications <br /> Depth of Grout Seal <br /> 17 Geophysical <br /> U Other Type of Grout / <br /> Surface Seal Installed by , <br /> Repair Work Done ❑ Type of Pump (�. �_ H.P. State Work Done <br /> Well Destruction U Well Diameter fi Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <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 ❑ 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 ❑ 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 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 ploy persons subject to workman's co ensation laws of California." <br /> The app lic s cal for requ Ved inspections. Complete dr i g on verse side. <br /> n <br /> Signed X Title: I Date: <br /> F R EPARTMENT USE ONLY <br /> ication Accepted by Area Stk 466 6 1 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date 7- `] C/ �� Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BYEDAHT�EPERMITN0. <br /> INFO <br /> `97 L6 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />