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APPLICATION FOR PERIN'iiT <br /> SAN �CAQLii: LOCAL HEALTH DISTRICT p <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Q <br /> � <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to coristruct 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 �J �.0 Subdivision Name <br /> Owner's Name ,L_"r)P,r Address (Phone <br /> Contractor's Name 1_? E V�L�LZNI'[�L1 License No. 3Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL F7 WELL REPLACEMENT DESTRUCTION U W <br /> PUMP INSTALLATION (] SYSTEM REPAIR. OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ^ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f ( Industrial U Open Bottom F� Manteca Dia. of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public [_� Other El Delta Type of Casing <br /> V Irrigation Approx. E] Eastern Specifications <br /> ❑ Cathodic Protection Depth <br /> Depth of Grout Seal <br /> 1-1 Geophysical Type of Grout <br /> U Other <br /> Surface Seal Installed by <br /> Repair Work Done ❑ rType of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing-Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _15< 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 ��� Y` ,;r� CapacityNo. 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 a No. 8 Length of-lines Total length/size <br /> FILTER BED Distance to nearest: Well _��_ Foundation A-5— Property Line d <br /> SEEPAGE PITS F-1 Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS y <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 issued, I shall employ persons subject to workman's compensation laws of California." <br /> a t ust cal f r all eq a inspections. Complete G rawing on Reverse sid . <br /> Sig Title: Date: <br /> -3 3C) <br /> / FOE;_9,0TMENT USE ONLY <br /> GL <br /> ;Application Accepted by L/ G[�AGL1s9Vs. Area � Stk 466-67$1 <br /> Additional Comments: Lodi 369-3521 <br /> Pit or Grout Inspection by Date �f Manteca 823-7104 <br /> Final Inspection by Date 3 3° fCj Tracy 835-6385 <br /> Applicant - Return all copies Environmental Health Permit/Services 1601 E. Hazeltor Ave., P.O. Box 20D9, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED y-RrE-,CEIVED BY DATE p PERMIT NO. <br /> INFO I L 0 �� <br /> EH 13 4* REV. lb%82 °`• 10/82 500 <br /> 14-26 <br />