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323 c, <br /> X�\ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � -- <br /> Tt, ��,��GE Telephone (209) 466-6781 <br /> DATE ISSUED 3—e' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i•`' .cu `�r is": �� l.IC. ;rG5ii1� (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 R gulations of the San Joa in o al H alth District. <br /> Job Address Subdivision Name <br /> Owner's Name Address Phone <br /> Contractor's Name icense No. � r Phone <br /> 111-1--1-111111 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> FlIndustrial U Open Bottom 0 Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private r-1 Gravel Pack ❑Tracy Dia. of Well Casing <br /> 17 Public ' CJ Other Delta <br /> Type of Casing <br /> U Irrigation Approx. ❑Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical <br /> Other Type of Grout <br /> U <br /> Surface Seal Installed by <br /> Repair Work Done [J Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence Commercial _ Other available within 200 feet.) <br /> If <br /> Number of living units: Number of bedrooms Lot size — W 1 <br /> Character of soil to a depth of 3 feet: ,�. Water table depth <br /> SEPTIC TANK Type/Mfg44XjEj� Capacity ,42 &aNo. Compartments <br /> r <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal c� w <br /> Distance to nearest: Well Foundation Za e' Property Line <br /> N <br /> LEACHING LINE No. & Length of linesTotal length/sizeIle Ara <br /> FILTER BED Distance to nearest: Well Foundation Property Line c., <br /> SEEPAGE PITS j° Depth Size /-00, Number e <br /> SUMPS l_I Distance to nearest: Well Foundation �Qr f Property Line o j <br /> DISPOSAL PONDS <br /> rn <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county N <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. cc9n � <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this No <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman§ compensation laws of Californ ;,'v' <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for w`{'iich " <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applica iu call for all qui I inspections. Complete drawing of r verse ide. <br /> Signed X—l�y�� — Title: _�1.�+ �[ Date: <br /> e4.x% ,X <br /> USE ONLYApplication Accepted Area ©� Stk 466-6781 <br /> Additional Comments: � 47 EJ Lodi 369-3621 <br /> Pit or Grout Inspection by -./ 83 q Manteca 823-7104 <br /> Final Inspection by _ Date _S _ 0 Tracy 835-6385 <br /> Applicant Return all copies t nvironmental Health Permit/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 /> 31 8--� <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 co <br />