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R APPLICATION FOR PFRMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO, I � . <br /> Telephone (209) 466-6781 DATE ISSUED � — <br /> 711 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 /> F described. This application is made in compliance with San Joaquir County Ordinance No. 549 for sewage or No. 1862 for well/pump < <br /> and the Rules and egiation of the San Joaquin Local Health District.. <br />! Job Address c�Ci Subdivision Name - -4- 4,07' 0 5 <br /> 4 ` y <br /> Owner's Name �'— Address �A� Phone <br /> Contractor's Name License No. :� Phone, <br /> _ N <br /> TYPE OF WELL/PUMP WORK: NEW{WELL WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U <br /> DI-STANCE:TO-.NE"AREST.:SEP.T.IC TANK_---_—---_,SEWE_R_LINES _DISPOSAL FLD. n PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I� Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation <br /> f Domestic/Private a ? <br /> ❑ ❑ Gravel Pack ❑Tracy Dia. of Well Casing <br /> ❑ Public FJ Ot'h�eDelta , Type of Casing <br /> II. ❑ Ireigation Approx, ❑ Eastern T.j Specifications r <br /> '4❑ Cathodic Protection Depth Depth of Grout Seal <br /> ❑Geophysical , 11ti1�ype of Grout <br /> }Other Surface Seal Installed by i F� ' C <br /> Repair'Work Dane ❑ Type of Pump. i H.P. State Work Done <br /> j t <br /> Well Destruction LJWell Diameter Sealing Material (top 50') <br /> f t <br /> ^Depth r .f . '' Filler Material (Below 50') 9 �r <br /> , <br /> TYPE OF SEPTIC' WORKS'} NEW INSTALLATION 'NREPAIR/ADDITION C) (No septic tank or seepage pit permitted ifrpublic sewer is <br /> available within 200 feet.) <br /> Installation will serve..'Residence V'Commercial _ Other g <br /> Number of living un)t`s�-A li'._-u ber of bedrooms' Lot size <br /> Character of soil to a depi of-3 feet: 00 13 1 Water table depth <br /> SEPTIC TANK s fyp1.e/Mfg', �9 Capacity No. Compartments <br /> PKG. TREATMENT PLT. LTJ Type/Mfg Capacity Method of Disposal <br /> t <br /> SEWAGE SYSTEM ❑ ­Di. tance to\nearest: -ileTl Foundation Property Line <br /> DESTRUCTION -` <br /> LEACHING LINE Tq eP No. &`,Length of lis Total length/size /i <br /> noun a Property Linei <br /> FILTER QED 'i ❑ Distanc�Ytoynearest:'aW IT a 'tion P Y <br /> 1 � - Sie. "Nu -« <br /> SEEPAGE PITS mber <br /> {. ❑ D,e�pth t��- 1,z , - <br /> SUMPS ❑� Distance to nearest: Well Foundation ,-_ Property Line <br /> DISPOSAL POND; ❑ <br /> y <br /> I hereby certify that I have prepared this application and the the work will'.-be-.done_i,n accogdance 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 certif�,es_the fo1J.owin9: "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 became'subject--to^workman t'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 must cal for 11 r uired inspections, Complete drawing on reverse side. <br /> ?l Signed X Title: f Date: ®� <br /> t1 DETMENT USE ONLY g <br /> Application Accepted by L Area ®� l ❑ Stk 466-6781 <br /> AdditionallNomments: I i ❑ Lodi 369-3621 <br /> I ' Date ❑ Manteca 823-7104 <br /> Pit or Grout Inspection by. <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return%all copies to: EnvironmLn a Health Perjpit�/Services 1601 E. HazeltonaAve., P.O. Box 2009, St k., CA 95201 <br /> nFEEBASE AMOUNT IDUE AMOUNT REMITTED yRECEIVED BY ) DATE PERMIT NO. <br /> E <br /> L EH -13-24 `REV. 10/82 �E 10/82 500 <br /> t 14-26 <br />