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APPLICATION FOR PERMIT <br /> \\ SAN JOAQLi"; LOCAL HEALTH DISTRICT� ^ s l� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. c� <br /> Telephone (209) 466-6781 .q-� <br /> DATE ISSUED s ,3 LLQ <br /> 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 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 e Sa Joaqui Local Health District. <br /> Job AddressSubdivision Name <br /> Owner's Name AddressJB-5e so . ✓ Phone 47,48-,M <br /> Contractor's Named? License No. Phone � SfGLL G� <br /> TYPE OF WELL/PUMP WORK: NEW WELL F] WELL REPLACEMENT DESTRUCTION �JJ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER Lj 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (A <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } <br /> IFI Industrial U Open Bottom 7 Manteca Dia. of Well Excavation N\ <br /> U Domestic/Private F-]Gravel Pack ❑ Tracy Dia. of Well Casing <br /> 17 Public F-1 Other ❑ Delta <br /> Type of Casing <br /> V Irrigation Approx. E] Eastern <br /> ❑ Cathodic Protection <br /> Depth Specifications <br /> Depth of Grout Seal <br /> 17 Geophysical <br /> Type of Grout <br /> L]Other <br /> Surface Seal Installed by <br /> Repair Work Done E] Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is rA <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other <br /> Number of living units: � Number of bedrooms � Lot size � X.20� <br /> Character of soil to a depth of 3 feet: �t Water table depth , <br /> SEPTIC TANK Type/Mfg �-6*C 1J 4, f� Capacity�,t1� No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM <br /> ❑ Distance t ar�: Jell p fenwdation �� ?reperty Line <br /> LEACHING LINE ❑ No. & Lengt of lines F y Total length/size r/ <br /> FILTER BED Distance to nearest: Wel Foundation _ Property Line <br /> SEEPAGE PITS Depth o Size kE� Number l <br /> SUMPS Ej Distance to nearest: Well Foundation l Property Line <br /> DISPOSAL PONDS ❑ Af%f <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 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 /> The applicant m st call for©11 required inspections. Complete drawing on reverse side. <br /> Signed X p D Title: 0�� D�, Date: 3 <br /> DE RTMENT E ONLY <br /> Application Accepted by Area — -- Stk 466-6781 <br /> Additional Comments: [] Lodi 369-3621 <br /> Pit or Grout Inspection by Date D Manteca 823-7104 <br /> Final Inspection by !i+/ Date 9/w —P ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AM RECEIVED BY DATE PERMIT NO. <br /> INFO O <br /> qVl 5 h3 ­93 <br /> EH 13-24 REV.. 10/82 �— 10/82 500 <br /> 14-26 <br />