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V <br /> APPLICATION FOR PERMIT ICANNED <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. a <br /> Telephone (209) 466-6781 � J �(�� <br /> � <br /> GATE ISSUED i ' �-�--� <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 Sari Joaquin Local Health District. <br /> Job Address ,� Q L I c.rL G subdivision Name <br /> Owner's Name 7 4' ✓ Addresst'� CI G Phone <br /> f> ??.�frc a_�� <br /> Contractor's Name f License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ,r h <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V" <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing <br /> Public Other Delta Type of Casing <br /> Li Irrigation Approx. Eastern <br /> Depth Specifications <br /> F-1CathodicProtection Depth of Grout Seal <br /> 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 U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR . DDI7 7D (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other cle- <br /> Number of living units: Number of bedrooms Lot size > 0 <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Dj'� Type/Mfg EGA- C.czr Capacity q No. Compartments 15 <br /> PKG. TREATMENT PLT. [� Type/Mfg GlLF' city Method of Disposal„G — [�' <br /> SEWAGE SYSTEM Distance to nearest: Well ,[.y e� ound ion.._�1 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 Lj Distance to nearest: Well 2-eVfi Foundationle, Property Line <br /> DISPDSAL 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 applicant mu t call for all required inspections. Complete drawing on reverse side. <br /> Signed K a �ek_e, Title: Date: <br /> FOR DEPAR ENT SE ONLY <br /> Application Accepted by ' n Area Stk 466-6781 <br /> Additional Comments: d4 (e> f Lodi 369-3621 <br /> Pit or Grout Inspection b Date L] Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copie to: Environmental Health Permit/ vices 10 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 13YDATE <br /> PERMIT NO, <br /> INFO "L3 (�3 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />