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50 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQLiri LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 3- X73 <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 !Y <br /> 1c� �,,j�����j��� Subdivision Name <br /> Owner's Name T)l9SE �[3iQ.tA /�+� C'f`NGYCiAl��,� Z 7� �. �2 Sht�% Phone JZ S—y0 <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ] WELL REPLACEMENT ❑ DESTRUCTION ] Ui <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ] y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> �1 I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS vC <br /> J Industrial U Open Bottom r-I Manteca Dia. of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack Lj Tracy Dia. of Well Casing <br /> I] Public G Other Delta <br /> Type of Casing <br /> V Irrigation Approx. Eastern f <br /> Depth Specifications <br /> (] Cathodic Protection j <br /> Depth of Grout Sea] <br /> Geophysical <br /> Type of Grout <br /> Other <br /> Surface Seal Installed by <br /> Repair Work Done ] Type of Pump H..P. State Work Done <br /> Well Destruction (] Well Diameter Sealing Material (top 50') _ .S . <br /> Depth Filler Material (Below 50') ) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION j] REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is JI <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 U Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal �1 <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line 1 <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 /> SEEPAGE PITS ❑ Depth Size i:`. Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <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 fo11Gwing: "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 workmant 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 applic n m t cal for 1 required in pections. Complete drawing on reverse side. <br /> Signed X Title: 4 Date: — ) <br /> DEPARTME S NL <br /> Ap ication Accepted by Area . Stk 466-6781 <br /> Additional Comment Lodi 369-3621 <br /> Pit or Grout Inspe- io Date Manteca 823-7104 <br /> Final inspection b Date (�—IL7Tracy 835-6385 <br /> Applicant - Return all opi to: Ervin ent Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 Rev. 10/82 FJ 10/82 500 <br /> 14-z6 f/ � <br />