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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. _�= �,_� <br /> Telephone (209) 466-6781 DATE ISSUED -7-15 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED Q F <br /> (Complete in Triplicate). <br /> 3�O S , ermit to construct and/or install the work herein <br /> Application is hereby made to the San Joaquin Local Health District for p <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for ewage - 1862 far well/Pump <br /> or Nom <br /> trict. <br /> and the Rules and Re ulatio s of the an joa2uin Local Health Cis �� � ; <br /> Job Address Subdivision Name <br /> Ad ress Phone h((��1'-3n! �� �(� <br /> Owner's NameLicense No. s Phone l �f <br /> Contractor's Name - <br /> TYPE OF WELL/PUMP WORK: NEW-WELL D WELL REPLACEMENT DESTRUCTION � J <br /> OTHER � '€ <br /> PUMP INSTALLATION A SYSTEM REPAIR U U PROP. LINE Q <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER WELL PITS/SUMPS <br /> FOUNDATION' AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial [J Open Bottom ❑ Manteca <br /> Dia. of Well Excavation <br /> Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public [j Other, Delta Type of Casing <br /> LJ IrrigationApprox. Eastern Specifications Iy, <br /> Depth Depth of Grout Seal `1' <br /> Cathodic Protection r� <br /> Geophysical Type of Grout <br /> [j Other r Surface Seal Installed by <br /> Repair Work Done G Type of Pump . H P <br /> State Work Done h <br /> Well Destruction Well Diameter+ Z i_ Sealing Material (top 50') C8�'ski <br /> Depth CCin Filler Material (Below 50') S <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/,ADDITION U (No septic tank or seepage pit permitted if ' 200 sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> I Number of bedrooms Lot size <br /> Number of living units: Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> � <br /> SEPTIC TANK Type/Mfg Capacity Method of Disposal <br /> Capacity <br /> PKG. TREATMENT PLT. Type/Mfg Property Line <br /> SEWAGE SYSTEM C] Distance to nearest: Wel} Foundation P R <br /> DESTRUCTION 3 <br /> LEACHING LINE U No. & Length of lines <br /> Total length/size <br /> FILTER BED Distance to nearest: Well <br /> Foundation Property Line <br /> — <br /> SEEPAGE PITS [—IDepth size Number <br /> SUMPS L—� <br /> 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 /> as to become subject to workman .compensation laws of California." <br /> permit is issued, S shall not employ any person in such manner <br /> Contractor's hiring or sub-contracting sinature certifies to the n�slocompensationrlaws ofaCalifornia�rformance of the work for which <br /> e this permit is issued, I shall employ persons <br /> The applicant must ca for all required inspections. Complete dra in reverse side. -Z—Z-3-93 3-9 3 <br /> Date: <br /> Title: <br /> Signed X <br /> F p T USE ONLY Stk 466-6781 <br /> k Area <br /> !!k Appl cation Accepted by Lodi 369-3621 <br /> Additional Comments: Date Manteca 823-7104 <br /> � <br /> Pit or Grout inspection c��i/� o Tracy 835-6385 <br /> � Date ��--� <br /> Final Inspection by <br /> Applicant - Return all cQp7. to: . virgn en al Hal 4h Permit/Services 16 E. z lton Ave., P.O. Box 2009, St k., CA 95241 <br /> VI LCL DATE PERMIT N0. <br /> FEE } BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> � INFO � --71 p <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />