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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> y I DATE ISSUED <br /> r v 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 workherein <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 San Joaquin Local Health District. lll► ©�_ +U <br /> Job Address 7986 Subdivision !Name <br /> Owner's Name SM/ 1&,Qj1V Address 9 hone <br /> Contractor's Name ��_ License No, Phone ]��- Q7 _ A <br /> TYPE OF WELL/PUMP WORK NEW WELL Q WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER j <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t IID Industrial U Open Bottom L Manteca Dia. of Well Excavation <br /> i <br /> 1-1 <br /> Domestic/Private Ej Gravel Pack F7 Tracy Dia- of Well Casing <br /> Public EJ Other Del to _ <br /> Type of Casing <br /> LjIrrigation i Approx. [] Eastern <br /> Specifications ' <br /> Cathodic Protection Depth - i <br /> Geophysical Depth of Grout Seal ti <br /> Type of Grout <br /> Other 1� <br /> Surface Seal Installed'by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Destruction U ,We`ll' Diameter Sealing Material (top 501) t <br /> -� Depth Filler Material (Below.50')-- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0-,'(No septic tank or seepage pit permitted'if public sewer is <br /> .'-;. . + 1 available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other <br /> Number of living units: Number of bedrooms - - Lot size, p <br /> Character of sail to a depth of 3a�����apacity <br /> LO'1 A Water table depth <br /> SEPTIC TANK Type/Mfg &AW No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> Distance to nearest: Well Foundation 7-0 Property Line _(�® <br /> LEACHING LINE No. & Length of lines — :90" Total length/size +Cd ,d <br /> FILTER BED Distance to nearest: Well Foundation Property Line / T <br /> SEEPAGE PITS Depth Size _ r�( Number <br /> i <br /> SUMPS LJ Distance to nearest: Well Foundation Property Line S �� <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 t compensation laws of-California." i <br /> Contractor's in or sub-contracting si ature certifies the following: "I certify that in the performance of the work for which <br /> this permit s s ed, I sha employ pe ons subject to workman's compensation laws of California." <br /> w i <br /> The appli nt 11 fa all req a insp�ttions. Comp]e dr on reverse side:• j <br /> Signed Title: Date, <br /> FOR P NT USE ONLY <br /> Application Accepted byA Area ( Stk 466-6781 <br /> Additional Comments: [] Lodi . 369-362.1 <br /> Pit:or Gout-Inspection by i Date Manteca 823-7104' <br /> Final Inspection by Date ts3 Tracy 835-6385 <br /> t Applicant Return all copies to: Environmental Health Pert/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 /> INFO <br /> EH 13-24 REV. 10/82 l 10/82 500 <br /> 14-26 <br />