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NOV, <br /> � APPLICATION FOR PERN�i' <br /> SAN JOAQUiI LOCAL HEALTH DISTRICT 1 <br /> i 3 N 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED I <br /> � t LOMPERMIT EXPIRES l 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. p�'-i l is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rule Reg �Is of the San Joaquin Local Health District. <br /> Job Address � (" als d L 10� Subdivision Name <br /> Owner's Name <br /> 6�- Address 1Phone <br /> No. Phone <br /> Contractor's Name License ().1 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U 04 <br /> PUMP INSTALLATION Fl.�S YSTEM REPAIR Cl, OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation <br /> — omestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing <br /> ❑ Public ❑1 Other ❑Delta Type of Casing <br /> Irrigation Approx. ❑ Eastern Specifications m <br /> ❑Cathodic Protection Depth <br /> Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> Other Q <br /> Surface Seal Installed by <br /> Repair Work Done FT--*T'YPe of Pump ,)�k H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') - I <br /> Depth Filler Material (Below 501 Jr- <br /> TYPE <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage piavaermitted ifpulable within blicfseter is I-� <br /> Installation will serve: Residence _ Commercial — Other �7i1 <br /> Number of living units: Number of bedrooms Lot size <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> �. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg <br /> Capacity Method of Disposal <br /> SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE F-1 No. & Length of lines Total length/size <br /> 17Distance to nearest: Well Foundation Property Line <br /> FILTER BED <br /> SEEPAGE PITSDepth Size Number <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> SUMPS L—I <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 workmanl; 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 issue I shall employ persons subject to workman's compensation laws of California." <br /> The applicant must 11 for all wired spect o Complete drawing reverse s;�?• Date: <br /> Signed X Title: <br /> F ENTUSE ONLY Area (j / ❑ Stk 466-6781 <br /> Application Accepted by (o <br /> ❑ Lodi 369-3621 <br /> Additional Comments: 55 Manteca 823-7104 <br /> Pit or Grout Inspection by Date <br /> Final Inspection by <br /> Date �� ❑ Tracy 835-6385 <br /> Applicant - Return all copi s nvironmental 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 /> I INFO � � �/�/g3 ����' <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />