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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> "r DATE ISSUED <br /> PERMIT 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 <br /> `LI Health District. <br /> Job Address e � fry ✓/lw Subdivision Name <br /> Owner's Name / Address �s � hone c_rJ <br /> Contractor's Name f icense N Phone I <br /> TYPE OF WELL/PUMP WORK: NEW WELL F� WELL REPLACEMENT `";-DESTRUCT.ION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <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 SPECIFICATIONS <br /> I Industrial U Open Bottom Manteca, Dia, of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public [J Other /) Delta Type of Casing <br /> [j Irrigation Ap r Eastern <br /> Depth Specifications <br /> [Cathodic Protection Depth of Grout Seal <br /> 0 Geophysical <br /> Type of Grout <br /> U 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') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JXj REPAIR/ADDITION [J (No septic tank or seepage pit permjtted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _✓ Commercial _ Other f— I <br /> Number of living units: Number of bedrooms S Lot size ��G7 161 S� i <br /> Character of soil to a depth of 3 feet: a Water table depth <br /> SEPTIC TANK 0 Type/Mfg / — tel. Capacity No. Compartments <br /> PKG. TREATMENT PLS'. [ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ r ' <br /> LEACHING LINE No. & Length of lines Z" Total length/size 70 (— <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth A. 71 Size Number Z <br /> SUMPS [ Distance to nearest: Well (V 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 following: "I certify that in the performance of the work for which this <br /> permit is issued, I shall not emple�as to become subject to workman compensation laws of California." <br /> Contractor's hiring or sub-contracignature certifies the following: "I certify that in the performance of the work for which <br /> this permit i k��eC <br /> emrsons subjgct to workman's compensation laws of California." <br /> The applican m �pections. Complete drawing�n reverse ide. <br /> X '^"�" Title: ^`f� ��..F, --r— <br /> Signed Date: �f <br /> R ART T USE ONLY <br /> Application Accepted by Area G3 Stk 466-6781 <br /> Additional Comments: Lodi 3 9-3621 <br /> Pit or Grout Inspection by Date `' 3 [ Manteca 823-7104 <br /> Final Inspection by ) Date Tracy 835-6385 <br /> Applicant - Return all copies to: ironmental 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 �� .]�_ f —7 10/82 500 <br />