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V /8' <br />APPLICATION FOR FERMI <br />fa. <br />SAN JOAQUI'; LOCA!. HEPITH DISTRICT <br />15CI E. HAZELTON AVE., STOCKTON, Cal s� 9 IT NO. 13 <br />%1 Telephone (209) 466-61814 ,w °.' <br />I7{ DATE ISSUED <br />PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED' --4149 11JA2 <br />(Complete in Triplicate) 19113yp L,;Jt% <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 S n Joaquin Local Health District. <br />Job Address Subdivision Name <br />Owner's NameAddress - Phone <br />Contractor's Name /Yi- !+7 Vicense No. 04 7 A /I Phone •rl ,A, tx, ,-I <br />TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br />PUMP INSTALLATION SYSTEM REPAIR LJ OTHER . U <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />0 <br />TYPE OF WELL <br />PROBLEM AREA <br />Indu rial <br />U open Bottom <br />Manteca <br />mestic/Private <br />❑ Gravel Pack <br />❑ Tracy <br />❑ Public <br />h <br />D It <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation _ <br />Dia. of Well Casing <br />[] t er Li e a <br />Type of Casing <br />{ J Irrigation Approx. Eastern <br />❑ Cathodic Protection Depth Specifications <br />Depth of Grout Seal <br />1-7 Geophysical <br />Type of Grout <br />Other <br />Surface Seal Installed by <br />Repair Work DoneType of Pump H.P. State Work Done <br />Well Destruction U Well Diameter Sealing Material (top 50') <br />Depth Filler Material (Below 501) <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j � (No septic tank or seepage pi,t permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence _ Commercial <br />Number of living units: Number of bedrooms <br />Character.of soilrto"a depth of 3 feet: <br />SEPTIC TANK. L Type/Mfg <br />PKG. TREATMENT PLT. 0 Type/Mfg <br />SEWAGE SYSTEM C Distance to nearest: Well <br />DESTRUCTION +--I <br />Other <br />Lot size <br />Capacity <br />Capacity <br />Foundation <br />Wate tabl� e depth <br />No. Compartments _ <br />_ Method of Disposal <br />Property Line <br />LEACHING LINE F-1 _ 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 IJ Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS D <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 workmant 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 issd, I shall mploy persons subject to workman's compensation laws of C I* ornia," <br />The applicant ueall for �u�iredspecti Complete drawl on reverse side. <br />01 <br />Signed.X le: Date: <br />FD� EPARTM NT ON <br />Application A cepted Area Q�i_ Stk 466-6781 r <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 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />FEE <br />BASE AMOUNT DUE <br />AMOUNT REMITTED <br />RECEIVED BY DATE PERMIT NO. <br />INFO <br />v <br />EH 13-24 REV. 10/82 10/82 500 <br />14-26 <br />