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'"aYr`3 <br /> APPLICATION FOR PERMIT d? <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT �� <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 pp <br /> DATE ISSUED <br /> / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) pQ,Zk <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein I <br /> described. This application is made in compliance with San Joaquin County Ordinance No, 549 for sewage or No. 1862 for well/pump CA CA <br /> and the Rules and Regulations of the,San Joaquin Local Health District, <br /> Job Address I Subdivision Name oc <br /> i, Owner's Name 1 Address , G Phone --5-1�-1 <br /> Contractor's Name �?a11,�i , t �, n License No..2 C1 Phone <br /> Nro <br /> I� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Ck <br /> C PUMP INSTALLATIONSYSTEM REPAIR OTHER ❑ r tN <br /> I <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 SPECIFICATIONS17 / <br /> Industrial Open Bottom ❑Manteca Dia. of Well Excavation <br /> Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing f <br /> Public Other Delta <br /> ❑ ❑ Type of Casing G/ <br /> V Irrigation c_964C Approx. [] Eastern Specifications - <br /> Cathodic Protection Depth — <br /> 4 4 <br /> F-1CathodicDepth of Grout Seal " <br /> f ❑ Geophysical Type of Grout qs S, Ile) <br /> LJ Other Surface Seal Installed by J_,; /Ird <br /> Repair Work Done [J Type of Pump J� H.P. State Work Done <br /> Well Destruction U Well Diameter Sea3ing Material (top 50') - \ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (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 ❑ 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'CINE—F]—N6.'& Length of' 1ines" Total length/size <br /> FILTER BED ❑ Distance to nearest: Well :Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation `. ' Property Line <br /> DISPOSAL PONDS ❑ C { <br /> I hereby certify that I have prepared this application and that the work willlbe 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 applicant Dust call for all requirCd inspections. Complete drawing'on reve`rse'side� <br /> Signed X Title: Date' <br /> 4 ' <br /> FOR ART T USE ONLY Stk 466-6781 <br /> Application Accepted by Area <br /> 1, ❑ <br /> � Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final inspection by Date ;Z a- ❑ 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 PERMIThNO.INFOp�r0 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />