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i1 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT q <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 3-3'- <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED i PIP <br /> (Complete in Triplicate) <br /> Application is hereby node 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/Dump <br /> and the Rules and Regulati-OAG Of the San Joaquin Local Health District. <br /> Job Address <br /> Subdivision Name <br /> Owner's Name �. <br /> - Address Phone <br /> Contractor's License No. �Z.6 <br /> Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION CJ SYSTEM REPAIR - OTHER [� W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> 0 CONSTRUCTION SPECIFICATIONS <br /> Ply. <br /> (] Industrial en Bottom <br /> (] OdmestiUPrivate �� D Manteca Dia. of Well Excavation <br /> LE]P best ` EJ Pack Tracy Dia. of Well Casing <br /> 0 Other Delta <br /> LJ Iv rigation iApprox. Type Of Casing <br /> Eastern <br /> EJ Cathodic Protection ; Depth ".Specifications <br /> �]Geophysical ` "�Depfh of Grout Seal <br /> cher Type of Grout <br /> . <br /> Repai r Work Done � TypeSurface SealInstalled by <br /> of' Pump H.P. State York Done <br /> Well Destruction Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (llel9w 50r)<<�= <br /> TYPE F SEPTIC WORK: NEW INSTALLATION ] REPAI DO TION <br /> (No SeDiIc tank or seepage pit permitted if public sewer is <br /> Insltallation will serve: Residence -X Commercial _ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms Lot size <br /> Cha lraTANK of soil to a depth of 3 f <br /> SEPTIegt; e <br /> C TANK [/� ' Nater table depth � O p <br /> Type/Mfg Qi a Capacity Zf7 O No. Compartments <br /> PKG. �REATMENT PLT. Type/Mfg capacity Method of Disposal <br /> Distance to nearest: Well undation ertY Line <br /> -4z Pr6 $ <br /> LEACHING LINE Not 8 Length of lines Total length/size .0 /Y <br /> FILTER BED Distance to nearest: Well Foundation - <br /> ? Property Line <br /> SEEPAGE PITS <br /> 4 Death5ize _ " Number <br /> SUMPS LI Distance to nearest: WellFoundation � Property LinS J <br /> DISPOSAL PONDS Ii - - e <br /> -- h <br /> i <br /> 13rrr�ssaaarmsr t <br /> I her certify that I have„prepared this application and that the work will be:done-in accordance with San Joaquin county <br /> Ordinahces, state laws, and-rules and regulations of the San Joaquin Local Hea7thTllistrict. <br /> Hone o(vner or it censedjagent'b signature certifies the following: "Icertify that”in-the perfOAXance of the work for which this <br /> rwo <br /> permit is issued, I shall 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 p <br /> ermit is issued, I shall. employ persons subject,to-workman's-compensation laws of-California." <br /> The applicant It call for all r fired inspe tions. Complete dra <br /> Signed Xiji9 on reverse side. <br /> Title: (�-L�i Date: <br /> DEP 1 fT USE ONLY <br /> Application Accepted by as Area 0 Stk 466-6781 <br /> Additional Comments: / Lodi 369- <br /> Pit or Grout Inspection by _ / .pate �7 3621 <br /> Manteca 823-36ZI - <br /> Final Inspection by pate 7104 <br /> Tracy 835-6385 <br /> Applicant - Return all copies ao: Environmental Health_Permit/Services-.16 E. el too Ave., P.C. Box 2009, Stk., LA 95201 <br /> {. I` <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. i <br /> ENFO <br /> EH 13-24 REV. 10/82 <br /> 14-1 6 10/82 500 <br />