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APPLICATION FOR PERMIT r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT s } <br /> ' 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 PERMIT N0, 3 <br /> PERMIT EXPIRES_1 YEAR FROM DATE ISSUED DATE ISSUED [ Q� <br /> Ff (Complete -in_Triplicate)Appl <br /> described. is hereby made to the San Joaquin Local Health Distract fora permit to construct and/or install the work.herein <br /> described, This application is made in with San Joaquin Count Ordinance No. 549 for sewage or No. 1862 for well/ um <br /> and the Rules and Regulations of the San Joaquin Locai .Health Distract, y <br /> Job Address g p p_. <br /> ' cq Subdivision Name <br /> - Owner's Name '— <br /> Contractor's NameAddress oAe2ze, <br /> At2 s License No. 2 Phone <br /> 3 Phone- 2 <br /> TYPE OF WE WORK; NEW WELL <br /> [] WELL REPLACEMENT DESTRUCTION❑ m 9J ' <br /> DISTANCE TO NEAREPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Q_\SEPFSF: IC TANK <br /> SEWER LINES DISPOSAL FLD. ""� <br /> FOUNDATION AGRICULTURE WELL ——� PROP. LINE <br /> INTENDED OTHER WELL PITS/SUMPS <br /> � DEU USE -��TYPE OF WELL PR0ILEM AREA <br /> E ❑ Industrial = CONSTRUCTION SPECIFICATIONS <br /> ❑Open Bottom ❑Manteca <br /> ❑ Domestic/Private Dia. of Well Excavation <br /> [JGravel Pack Trac <br /> ❑ Public y Dia, of Wel] Casing <br /> EJ Other Delta <br /> LjIrrigation <br /> AType of Casing' <br /> EJ Cathodic Protection Depth <br /> Eastern g <br /> Specifications'" <br /> 0 Geophysical Depth of Grout seal <br /> ❑Other Type of Grout r <br /> —� <br /> Repair Work Done EJ_ Surface Sea] Installed by <br /> Type of � <br /> Well Destruction � � __ State,Work Done <br /> _.U._Well Diameter n - "--- <br /> g- Mater+ial {top 50 <br /> Depth <br /> Seali <br /> 'Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f J REPAIR/ADDITION <br /> (No septic tank <br /> Installation will serve: Residence LU (No seepage pit permitted if public sewer is' <br /> Commercial Other available within 200 feet.) <br /> Number of living units: <br /> Number of bedrooms 'Lot size /p q <br /> Character of sail to a depth of 3feet: _ C + <br /> SEPTIC TANKOf <br /> jZZj Type/Mfg t Water table depth <br /> PKG. TREATMENT PLT. 0 Type/Mfg Capacity _ No. Compartments <br /> � <br /> Capacity Method of Disposal <br /> Distance to nearest: Well �� Foundation <br /> Property Line C] <br /> LEACHING LINE A No. & Length of lines �- <br /> FILTER BED 001 Total length/size �p <br /> Distance to nearest: Well /,up Foundation - <br /> SEEPAGE PITS — _ Property Line S o <br /> SUMPS ❑ Depth. /0— Size Number —^ <br /> J Distance to nearest: Well ro Foundation ! <br /> .DISPOSAL PONDS ❑ � Property Line <br /> T hereby certify that I have prepared- this application and that the work will be done in accordance` with S­jXoaquin ,count + <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 foilowin y <br /> Permit is issued, I shall not employ an g- "I certify that in the performance'of the-"work for which this <br /> p Y y person in such manner as to become subject to workman§ compensation Taws 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 employipersons subject to workman's compensation laws of California." <br /> The applicant must � I for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: <br /> R D ARTMEDate: <br /> Application Accepted by ONLY <br /> Additional Comments: Area _4 <br /> om— Stk 466-6781 <br /> Pit or Grout Inspection by f Lodi 369-3621 <br /> Final Inspection by Date anteca 823-7104 <br /> Applicant - Return all copies Date ❑ Tracy 835-6385 <br /> p Enver mental Health Permit/services 16 . E. azelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r)EqFo <br /> BA E AMOUNT DUE k AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. <br /> c � Sr <br /> r <br /> EH 13-24 REV. I0/82 <br /> 14-26 <br /> @ 10/82 500 <br />