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-- APPLICATION FOR PERMIT <br /> SAN JOAQU24 LOCAL HEALTH DISTRICT I /� <br /> 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. S'Lt- 1J <br /> Telephone (209) 466-6781 <br /> DATE ISSUED �1 <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 permit to construc�a�"or&SPhYwork herein <br /> PP y 9 P / <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 nd// Regulations of the San Joaquin Local Health District. <br /> Job Address a_c:® 1- E_ 4oe'•.�e_ Subdivision Name <br /> Owner's Name it Q lF- Address Phone <br /> Contractor's Name �r r-�� ���{ License No. if ht;kf4 Phone ily,311 7flm <br /> TYPE OF WELL/PUMP WORK: CNEW2WEL WELL REPLfiCEMEN7 DESTRUCTION <br /> PUMP ION 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 /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> Industrial U Open BottomManteca Dia, of Well Excavation <br /> Domestic/Private Gravel Pack racy Dia. of Well Casing rj <br /> Public Other ❑ Delta / <br /> Type of Casing <br /> LjIrrigation Approx. 0 Eastern <br /> L] Cathodic Protection <br /> Depth Specifications /T�� ,r41 <br /> Depth of Grout Seal <br /> Geophysical <br /> Type of Grout {�� H 1 -� _ 0 <br /> Other 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 U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is y <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 Ej Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Type/Mfg Capacity Method'of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS I-1 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 workman 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 applican t cal for 11 required inspections. Complete drawinn reverse side. <br /> Signed X Title: Date: <br /> PAR7MENT USE Y <br /> Application Accepted by Area �(� - - Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by ► Date Manteca 823-7104 <br /> Final Inspection by Date L Tracy 835-6385 <br /> Applicant - Return all copies to: nvironmental Health Permit/Services 16 1 E. Ha el ton Ave., P.O. Box 2009, Stk., CA 95201 ; <br /> FEE BRSE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. j <br /> INFO 143 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />