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_ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � �3 <br /> Telephone (209) 466-6781 <br /> DATE ISSUED �3j gy <br /> SAN N LOCAL L PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> E LTH DISTRICT (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 <br /> of the San Joaquin Local Health District. <br /> Job Address <br /> Owner's Name -,Ap,,�„f_ �(�a + Address hone <br /> V -TYPContractor's NameJt�� / License No. �°��. YfnGJ/�a Phone IV— <br /> TYPE <br /> E OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT E] DESTRUCTION <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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom 7 Manteca Dia. of Well Excavation <br /> LJ Domestic/Private Gravel Pack F_� Tracy Dia. of Well Casing <br /> El Public [-1Other Delta Type of Casing <br /> V Irrigation Approx. Eastern l <br /> Depth Specifications r <br /> F-1CathodicProtection p Depth of Grout Seal <br /> Geophysical Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done [X Type of Pump H.P. State Work Done /4'�►^ <br /> Well Destruction U Well Diameter Sealing Material (top 50') lb <br /> Depth Filler Material (Below 50' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION E) (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 U <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. 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 [f 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 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 applican must c for all required inspections. Complete dr wing on reverse side. <br /> Signed X Title: Date: 2- <br /> -� R PARTMENT U E ONLY 1-f� � <br /> Application Accepted by 42 _ Area Stk 466-6781 <br /> Additional Comments: di 369-3621 <br /> Pit or Grout Inspection y MIA DateManteca 823-7104 <br /> Final Inspection by a-4, Dates--7—8�' ����L���Tracy 835-6385 <br /> Applicant - Return all copies 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 /> ��s, c^ Com-- /g�~I SSLA —� <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 g $� <br />