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a� <br /> APPLICATION .FOR PERNiIT <br /> SA.N JOAQUIN LOCAL n=A,LTH 31STRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE I55UEG ' 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 Regulations of the San Joaquin Local Health District. <br /> Job Address r <br /> C /1'?T—Subdivision Name <br /> Owner's Name — Address / � <br /> Contractor's Name License No. Phone / <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR jJ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM'ARER CONSTRUCTIONSPECIFICATI0N5 <br /> I� Industrial U Open Bottom F� Manteca Dia. of Well Excavation <br /> U Domestic/Private f-] GravelPack ❑ Tracy Dia. of Well Casing <br /> Public Ej Other Delta <br /> irrigation Type of Casing <br /> ation A <br /> i 9 Approx. Eastern —r <br /> Cathodic Protectiony. Depth Specifications �n <br /> (]Geophysical W Depth of Grout Seal VjAI <br /> Other Type of Grout Ur1 <br /> Surface Seal Installed by J- <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1K REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> j f available within 200 feet.) Ic <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 TANKType/Mfg �� Capacity No. Compartments ?) <br /> PKG. TREATMENT PLT. Type/Mfg Capacity 7~^ Method of Disposal 1 <br /> SEWAGE SYSTEM Distance to nearest Well Foundation ' Property Lire <br /> DESTRUCTION o- <br /> LEACHING LINE LJ No, & Length of Tines-_._ -,,a O /517y.-i< Total length/size <br /> FILTER BED ,Distance toYnearest: 'Well - �_-(.Foundation', la �F� Property Line— "` a <br /> SEEPAGE PITS; C1 Depth Size f k lNumbe'r <br /> k SUMPS Lj Distance to'nearestc Well Foundation- t Property Line <br /> � DISPOSAL PONDS �j *�" � -Y-- .t � � <br /> ,.I-hereby certify that..l have`pre pa red 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 ]oaquinr1-oSal, 'Health District"" <br /> Home owner or licensed agent's signature,certifies the following: "I certify that.in the_performance_of the_w_ork for which-this <br /> permit is issued, I shall not employ any+-person.in-such-manner as to became,subject to_workman t compensation laws ofCCaTifornia." <br /> -Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the per'Formance of`the"wo-rk fd�rih.ich <br /> this permit is issued,"'I shall employ persons subject. to workman's compensation laws of California." { <br /> The applicant must call yors l required;inspections. Complete. drawing on reverse side. ' <br /> SignedA--. •_ ic./ - TiitI.e: ' Date: <br /> j,,FOR DEPARTMENT USE ONLY <br /> Application Accepted by Area °+ QZStk - 466-6781 Y� <br /> Additional Comments: Lodi 369-3621 <br /> tt Pit or Grout Inspection by } Date r Manteca 823-7104 <br /> N Final Inspection by Date 0 J Tracy 835-6385 <br /> Applicant - Return all cop(/ <br /> op' to: Environmental Health Permit/Services 1601`E. Hazelton Ave., P.Q. Box 2004, Stk., CA 95201 � <br /> * FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . wEH-13-24_ REU:_10%82r `' - - "� 'z _-� 10/82 500 - l <br /> 14-26 <br />