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- APPLICATION FOR PERMT —� <br /> SAN JOAQLIN LOCAL,HEALTH DISTRICT Q <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 1l 3`f 0 6, <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ oinstot re"ndescribed. This application is made in compliance with San Joaquin County Ordinance No. 549 fors o8 or well pump <br /> and the Rulesd Regulations of the San Joaquin Local Health District. <br /> Job Address P�ou 1"teCTO N R� Subdivision Name <br /> Owner's Name AQ<eL MAC NOOG Address <br /> Phone <br /> Contractor's Name �� C.gQ�,�l License No. ��/�"}/$ Phone &--3 �5 t <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 1. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C�l <br /> J Industrial U Open Bottom p ❑ Manteca Dia, of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> !17 Public F-1 Other Delta <br /> Irrigation Type of Casing <br /> V g Approx. � Eastern <br /> Cathodic Protection Depth Specifications <br /> Geophysical <br /> Depth of Grout Seal <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done F] Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth' Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage-'pit permitted if public sewer is 0 <br /> available within 200 feet.) QN <br /> Installation will serve: Residence X Commercial _ �Otther <br /> Number of living units: r rNumber of bedrooms .0 Lot size A C C <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Ej Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal <br /> Sr.EWAGE SYSTEM Distance to,nearest: Well Foundation Property Line <br /> DESTRUCTION Q <br /> LEACHING LINE NJ No. & Length of lines �� Total length/size <br /> FILTER BED Distance to nearest: Well s�' Foundation /dI Property Line 710' �Qjx Zf <br /> SEEPAGE PITS ❑ Depth size 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 following: "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 applicant call for all r uired inspections. Complete drawing on reverse side. q G <br /> Signed X (�a�` p. Title: Date: <br /> RTMENT USE ONLYPA <br /> Application Accepted by A -OR DEPA Area U Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> E Final Inspection by (r �,( � �� Date {7 Tracy 835-6385 <br /> Applicant - Return all copie�to: . Environmental Health Permit/Services 1601 E. Hazelton Ave, P.O. Box 2009, Stk., CA 95202 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO <br /> INFO � Z f - -• <br /> EH 13-24 REV. 10/82 ` Q�i �/�-3 10/82 500 <br /> 14-26 <br /> rar <br />