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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT- S4' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. SSI—S LN) <br /> f' Telephone (209) 466-6181 DATE ISSUED S/3i42k <br />_ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r (Complete in Triplicate) <br /> Application is hereby made to the An '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 Joaq in County Ordinance No. 549 for sewage or No. 1862 for we <br /> and the Rules and Regulations of t1 SP Joaqui ocal ea rict. <br /> �—�{ ,� ?_ <br /> Job Address 'r�1`�` � � u i Sion Na e <br /> :Own is Name L i &)J&0V'PX Address Phone <br /> Contractor's Name E' a No. Phone <br /> r <br /> TYPE OF WELL/PUMP WORK: NEWSWELL L REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP ]NSTLRTION SYST <br /> RLEM REPAIR OTHER Lj <br /> DISTANCE TO NEAREST: SEPTIC TANK .� SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE 05.4t LL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Indus ial ❑D jBottom [] Manteca + x Dia. of Well Excavation <br /> ❑ Do stic/Private Gravel Pack Tracy Dia. of Well Easing f y <br /> ublic }Other ❑ Delta Type of Casingi�a t6� <br /> -— <br /> V IrrigationApprox, ❑Eastern Specifications <br /> Cathodic Protection +Y <br /> tion Mth <br /> ❑ ,• Depth of Grbut Seal <br /> Geophysical Type of GrautIN <br /> Q. <br /> Other <br /> L1 5urfac`e Seal Ins all ed by <br />!_ <br /> Repair Work Done ❑ Type of Pump Il P. State Work Done <br /> o Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> O f <br /> �Y' Depth Filler Material (Below 50') <br /> Ct TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (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: 1 Number of bedroomsLot size <br /> ' • Water table depth <br /> Character of soil to a depth of 3 feet: p <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> ` PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> t SEWAGE SYSTEM Distance to nearest: Wel-1 Foundation Property Line <br /> DESTRUCTION <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest; Well Foundation Property Line <br /> i <br /> SEEPAGE PITS- ❑ Depth Size, Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> application and that the work will be one n accordance with San Joaquin county <br /> I hereby certify that I have prepared this app dict1 <br /> ordinances, state laws, and rulesfand 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 any person in such manner as to become subject to workmang compensation laws of California." 1. <br /> Contract4no <br /> ' hiig or su c trot natu rtifies the following; "I certify that in the performance of the war for w 'ch- l� <br /> this perued I 1 aq <br /> s ubj t to workman's co ensation laws of California.The applo a ion Complete i <br /> Signed X <br /> Title: W Date: <br /> R DEPARTMENT USE ONLY —.—�`�— ❑ Stk 466- 81 <br /> Application Accepted by Area <br /> Additional Comments: Lodi 369-3621 <br /> Pit or rvu Inspection by. Date �_01 ❑ Manteca 823-7104 <br /> Final Inspection by Date/ ❑ Tracy 835-6385 <br /> Applicant - Return all copies to; Environ al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952Di <br /> r FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PLl <br /> ER�Nll�jINFO � _ <br /> —V <br /> I0/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br /> L f: <br />