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APPLICATION FOR PE;M':T <br /> SAN JOAQLIN LOCAL HEALTH D.SIRICT c <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT N0. <br /> Telephone (209} 466­5781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) C4 <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 ��L 4 46ZYL7111790r0 Subdivision Name <br /> Owner's Name Ey+-AiA.g Address -jVj ,p <br /> Phone'? Z•--44237 <br /> Contractor's Name �/���3�Q/ � � License No. Phone V6& <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATIONSYSTEM REPAIR <br /> ❑ ❑ OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> a FOUNDATIONAGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I_J Industrial ❑ Open BottomManteca <br /> ❑ Dia. of Well Excavation <br /> U Domestic/Private Gravel PackTrac <br /> ❑ ❑ y Dia, of Well Casing <br /> Public <br /> Ej Other Delta <br /> LjIrrigation Type of Casing <br /> Approx. Eastern <br /> ❑ Cathodic Protection Depth Specifications <br /> (❑Geophysical Depth of Grout'Seai ' <br /> LJOther Type of G"rout <br /> �1 <br /> Repair Work Done EJType of Pump H.P. Surface Seal Installed by <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth F <br /> P Filler Material {Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E-I REPAIR/,ADDITION (No Septic tank or seepage pit permitted if public sewer is <br /> ` <br /> Installation will serve:. Residence _kCommercial _ Other available'withim 20D feet.) <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 " ' <br /> Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg r 7—'° Capacity T Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well a Foundation Property Line <br /> DESTRUCTION ❑ <br /> F <br /> LEACHING LINE 'E No. & Length of lines Total length/size <br /> J� S <br /> FILTER-BED <br /> Distance to nearest: Well Foundation d0 ' Property Line _,57'° . <br /> SEEPAGE PITS Depth Size <br /> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line ; <br /> DISPOSAL PONDS ❑ <br /> r. <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 workmanS 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 i issued, I shall employ persons ubject to workman's compensation laws of California." <br /> The applica all f all r red ctiOfns. Complete drawing on reverse side. <br /> Signed x Title: -� <br /> � �,w/.E�' Date:' �� d <br /> 4 <br /> F EPARTMENT,�JSE ONL <br /> Application Accepted by p( d� Area �3 LJ Stk 4666781C <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104Final Inspection by ,Date —/&f43 �,� Tracy 835-6385 <br /> Applicant - Return all copiesto: Environmental Health Permit/Services 1601 E. Hazelton Ave. P.O. Box 2009, Stk., CFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />