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4 r APPLICATION FOR PERMIT <br /> h: �+ SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> R t 1501 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. <br /> -, Telephone (209) 466-6781 <br /> DATE ISSUED �3 <br /> _ PERMIT EXPIRES 1 YEAR FROM DAT E. ISSUED <br /> (Complete in Triplicate), ' 7 <br /> Application-is hereby made to 'the San'Joaquin Local"Health District for a periit 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-San Joa uin Local Health District. { <br /> Job Address o, Subdivision Name <br /> Owne Asa Name. Address c; Phone <br /> 'max "F Contractor's Name LLicense No. ���aPhone _�� 2 —�j{���. <br /> TYPE OF WELL/PUMP WORK: NEW WELL L] WELL REPLACEMENT y❑ DESTRUCTION 7 <br /> PUMP INSTALLATION SYSTEM REPAIR i OTHER U <br /> DISTANCE TO NEAREST:_SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION t AGRICULTURE WELL OTHER 14ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation G> <br /> Domestic/Private' ❑ Gravel Pack Tracy Dia. of Well Casing <br /> 17 Public <br /> Cj Other­,.� . Delta p ,,..... Type,of Casing - <br /> ❑ irri"gation —Approx---],Eastern-.-,.�.� --a.,-Specifications <br /> [ Cathodic Protection Depth , <br /> Geophysicalt ©epth of Grout Seal <br /> ,.Type.of Grout { I <br /> J Other x urface Seal ,Installed by <br /> Repair Work Done Ell Type.of Pump -- +-H-P.� -----...�.,-..-�--State..Work Done ; -« <br /> Well Destruction U Weill Diameter,: Sealing Material (top 50') <br /> f Depth E 1: Filler Material (Below 501) 1 <br /> TYPE OF SEPTIC WORK: NEW: INSTALLATIQN L-I REPAIR/ADDITION ` (No septic tank or seepage pit!permitted if Qublic sewer is v ' <br /> available within 200 feet.) <br /> Installation will serve; Residence Commercial Other i <br /> Number of living !In its: !Number of bedrooms --- Lot size <br /> Character of soi l,to a depth. of 3 feet: Water table depth <br /> SEPTIC TANK l I CI J Type/Mfg _�_ _._— �- Capacity No. Compartments l <br /> PKG. TREATMENT PLT„ <br /> Type/Mfg Method of Disposal; t <br /> SEWAGE SYSTEM Jistance'to nearest: Well Foundation PropertyZLine <br /> DESTRUCTION ❑ ( } <br /> LEACHING LINE U No. & Length of lines Total length/size i ti <br /> I <br /> FILTER BED i <br /> s� tDistance to nearest: Well Foundation Propert^ine �. <br /> SEEPAGE PITS/ e[� ; Depth size Number <br /> SUMPS e U 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 Slaws of California." <br /> Contractor's hiring'-or-sub=contracting#s-ignature-certifies-the-fol•lowing•;- I- r-ertify�that i-n-the-performance_o.f,.the-,wor_k-f;or,,.wh.i.ch.-",- <br /> t ermit is issued, shall empl persons subject to workman's compensation laws of California." <br /> The applica s all r a ed in cti s' Complet rawingso `reverse side. ^� <br /> Sign Title: Date: <br /> OR DEPARTM USE ONLY <br /> Application Accepted by C ,n/,q-hrypAreaQ mC k�O i JZ Stk 466-67$1 <br /> Additional Comments: Lodi 369-3621 <br /> � 1 <br /> Pit 'or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date Z'�/" p� ❑ Tracy 835-6385. <br /> Applicant - Returnall copies to: vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f <br /> 3 <br /> FEE BASE'€ AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT t�0. <br /> INFO <br /> qV <br /> EH 13-24 REV. 10/82 10/B2-5-00 <br /> 14-26 4. <br /> Y <br />