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r,r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQLiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <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 the San Joaquin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name �±Ql1� A7� Address n G�$ Phone <br /> Contractor's Name //� �IgQ6��G License No. 244 1 Ci Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT E] DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER �J <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 /> 17 Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> LJ Domestic/Private F-� Gravel Pack Tracy Dia. of Well Casing <br /> Public Ej Other Delta � Type of Casing <br /> Lj Irrigation Approx. Easr Specifications <br /> Cathodic Protection Depth ''' - <br /> [J Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> l-1 Other Surface Seal Installed by <br /> Repair Work Done ❑ 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 INSTALLATION L1 REPAIR/ADDITION [:D (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <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 TANK F-1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. E] Type/Mfg Capacity Metfiod of ISisposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE [j No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <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 an person in such manner as to become subject to workman compensation laws of California." <br /> ' Contractor's hiring or'"suTi-`contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ ersons subject to workman's compensation laws of California. <br /> The applica ust ca fo ll requ' d inspections. Complete drawing on reverse side. <br /> Signed X V� <br /> Title: � Date: <br /> FOR DEPARTMENT USE ONLY Area Stk 466-6781 <br /> Application Accepted by <br /> Lodi 369-3621 <br /> Additional Comments: <br /> Pit or Grout Inspection by <br /> Date El Manteca 823-7104 <br /> Final Inspection by <br /> Date E) Tracy 835-6385 <br /> Applicant - Return all_cap.ies to: Environmental 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 /> 10/82 500 <br /> EH 13-24 REV. 10/82 e <br /> 14-26 <br />