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x <br /> APPLICATION FOR PERMIT <br /> SA.N. JOAQUIN LOCAL HEALTH OISIRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-5781 <br /> PERMIT EXPIRES 1 YEAR FRCM DATE ISSUED. DATE ISSUED <br /> (Complete in Triplicate) <br /> u <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 andRegulationsof 4he San Joacuin L cal Health District, <br /> Job Address � f Subdivision Name <br /> Owner's Name Address Phone <br /> .T( <br /> Contractor's Name ° ijense=No. Phone .-7 2,L-]-- 9J-.. � <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP.,INSTALLATION ❑ SYSTEM REPAIR OTHER 61 <br /> DISTANCE TO NEAREST: SEPTIC-. 'AAK r� SEWER LINES DISPOSAL FLD. PROF. LINE -30 ^4 { <br /> FOUND$TNQ AGRICULTURE WELL OTHER WELL PITS/SUMPS ; <br /> INTENDED USE :' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IJ Industrial ,-r Open-Bottom "—E-Manteca--- --Dia::"of,Wel-l-Exca•vatio-n' <br /> Domestic/Private 0 Gravel Pack Tracy Dia. of Well Casing g �� <br /> Public F-1 Other Delta r' l y <br /> L_i Irrigation Type of •Casing <br /> �fl Approx. ❑ Eastern <br /> [] Cathodic Protection. i Depth Spec ificat s•,--" <br /> ­S <br /> ti <br /> Depth of Grout Sea <br /> Geophysical <br /> ,�I (Type of Grout <br /> Odie} i Surface Seal Installed by' ,g _-�. <br /> Repair;work-,Done Type of, Pump H.P. State Work Done <br /> well 6estructi'on U Well Diameter Sealing Materi top 501) <br /> Depth Filler Mat ial (Below 50') <br /> y,TYPE OF SEPTIC UORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if. public sewer is <br /> ava-ilable within 200 feet.) <br /> [n"stal.lation will serve: Residence ommer.cial _ Other f <br /> N'm of l ivisn'g units: I! Num ger of bedrooms Lot siie <br /> Character k 1­of 1. soil to a�depth of 3 feet:. Water table depth <br /> SEPTIf-TANK> K]e Type Mfq.,._v«. + -�"" Capacity No. Compartments. <br /> PKG. 'TR-EATMENT`PLT. Type'/Mfg , ^Capacity , - ethod:.of Disposal F <br /> SEWAGE SYSTEM Oi'stance to nearest: we]:1- Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE �--LJ No. & Length of lines Total length/size <br /> FILTER BED Ei Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS F-j, Depth Size Number <br /> SUMPS %-,Distance_to.:nearest:-Wel.l_.,_,_--_ ti_Eoundata.on_.�� ---._,_Property_Line­_ <br /> DISPOSAL PONDS <br /> I hereby certify that I haven, 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 I <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 /> TheOapp]icant mus require 'nspec mplete.drawi,ng on everse si e. <br /> Signed Xa tle: _ -w <br /> ' i�: FOR DEPA M ONLY {� q <br /> pplication Accepted by Piga i a, 5�,Stk 466-6781 <br /> Additional Comments: a. E Lodi 369-3621 <br /> Pit or Grout Inspection b Date U Manteca 823-7104 <br /> Final Inspection Date = _5 - 7 Tracy 835-6385 I <br /> Applicant - Return all c s to: Enviro ntal ealth Permit/Services 1601 E. Hazelton Ave- P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FFF BASE 'AMOUNT DUE AMOUNT REMITTED RECEIV(D BY DATE PERMIT NO. <br /> INFO I E <br /> ..:`.�•� -,-••w ...n.,. :: k l=f r '_ , I `"°'t; _ 10/82.500 <br /> 14-26 <br />