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h <br /> APPLICATION FOR PERMIT <br /> a SAN JOAQUiN LOCAL HEALTH DISTRICT Q� <br /> 1601 E. HATELTON AVE., STOCKTON, CA PERMIT NO. U 3 <br /> Telephone (209) 466-6781 <br /> DATE ISSUED y <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> e Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> F 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 Regulati.ons of the San Joaquin Local Health District. <br /> Job Address 5� IW D 5-;— Subdivision Name <br /> I Owner's Name Address _J2e1`C• MAP4E 53- S Phone <br /> ` Contractor's Name 4,> License No. 42�&,2 J( Phone <br /> 4 rpbl <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM,REPAIR LJ OTHER F-1 } <br /> DISTANCE TO NEAREST:_ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ((! ! <br /> W- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia, of Well Casing <br /> 1-1 Public F_ Other Delta Type of Casing <br /> L, Irrigation Approx. ❑ Eastern Specifications <br /> Cathodic Protection Depth <br /> Geophysical Depth of Grout Seal <br /> Type of Grout <br /> LJ Other <br /> Surface Seal Installed by <br /> Repair Work Done D 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 D REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> Al available within 200 fee .) <br /> Installation will serve: Residence Commercial Other W W <br /> Number of living units: Number of bedrooms 2- Lot size ! <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity 12.0e, No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well //, Foundation IQ r Property Line ? <br /> DESTRUCTION <br /> LEACHING LINE U No. ength of lines Total length/size stanc <br /> FILTER BEDxe to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS l5 to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> F <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 must cal for al required sp ctions. Complete dr ing on reverse side. <br /> Signed X Title: �, _ Date: <br /> OR EPARTM <br /> Application Accepted by Area Stk 466-6781 <br /> Additional Comment : Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> i Final inspection by Date -q :03 Tracy 635-6385 <br /> Applicant - Return all co i /; Environmental 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 /> i EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br /> f <br />