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c <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH'DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> ' llDATE I5SUED <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 k <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for we <br /> and the Rules and egulations of�itthenJoaquin Local Health District. l <br /> Job Address V A) Subdivision Name �, �Qddress a +E Z© �`C� P��—Owner's Name P <br /> Contractor's Name License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r, <br /> ;......- _._ ... . .... PUMP'iNSYACLATION`-.❑,.�--SYS'F•EM RE-PAI-R•.•.'r"(� OTHER.[-]•_W- .. : i)� ; <br /> DISPOSAL FLD. , " PROP. LINE'• <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES n <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS'. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial F-1openBottom ❑Manteca Dia. of Well Excavation <br /> i <br /> ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. o�'Well Casing <br /> ❑ Public ❑OtherDelta R .-.�. <br /> ❑ ',l Type-of.CIng'r ` <br /> ❑ Irrigation Approx. ❑ Eastern Specifieations <br /> ❑Cathodic Protection Depth <br /> Depth of Grout Seal <br /> ❑Geophysical Type of Grout ' <br /> F-1 Other Surface 'Seal Instal l ed''hy } <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done E <br /> 5 Well Destruction ❑ Well Diameter Sealing Material (tap 50') — <br /> ' Depth Filler Material (Below 50')- t <br /> } <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRJkODIT'ION ('No.'seQtid tahk`or seepage p�avaelableewithinu200cfete) is <br /> j <br /> Installation will serve: Residence commercial _ Other A-C- <br /> Number of living units-, Number of bedrooms -- Lot -size <br /> Water table depth <br /> Character of soil ,to a depth of 3 feet: r, - <br /> L Capacity - No. sGompa,rt pts <br /> SEPTIC TANK ❑ Type/Mfg i <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity � .:- Me#hood of .O �posal <br /> ( SEWAGE SYSTEM Distance to nearest: Well Foundation. Property Line <br /> ? DESTRUCTION Cl <br /> LEACHING LINE No. & Length of 'lines_ S - J--Tota 1-lengthyie <br /> FILTER BED Distance to nearest: Well Founda£ion Property,'rtine } <br /> , i <br /> ' Size w - :,,.Number. —..---- >�, <br /> SEEPAGE PITS ❑ Depth <br /> SUMPS D Distance to nearest:. Well Foundation .. -: vrop&ty4-e <br /> { DISPOSAL.PONDS ❑ S_'H` �_ , i <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquih county <br /> ordinances,'state laws, and rules and regulations of the San Joaquin Local Health District. ` <br /> Home owner-Dr licensed agent's signature certifies the following: "I certify that,in the performance of the work for'which this <br /> per�iit is issued, I shall not employ any person in such manner as`tb beccPme subject to workman compensation laws:of California.." <br /> u Contractor's hiring or sub-contracting signature certifies thejoll'owing: "I certify that in thejperfvrmance of he work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> f f The applicant must ca11 f a quire spections.. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date. p <br /> FO D PARTME_NT USE ONLY * i' <br /> Area h .­d 5tk 466-6781 <br /> Application Accepted by EJ Lodi Lodi x`'369-3621 <br /> y <br /> Additional Comments: } j <br /> Date ❑ Manteca 823-7104 , <br /> Pit or Grout inspection {- f <br /> i Date �V ❑ Tracy 835-b385 • . <br /> Final Inspection by.. <br /> Applicant - Return all 'cdpies to: Environmental Hea1'th Permit/Services 1601 E. Hazelton Ave., P.O. Bvx 2009, Stk CA 95201 <br /> ! e <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE-• PERMIT NOS. <br /> 1- INFO g ars <br /> :.- A;�-=:�-�------� 10%82 500 <br /> EH 13-24 Rf�V. 10/82 <br /> 14-26 <br />