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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> i 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 Sar J aquin Local Heal tT'Sjsstkiicct. <br /> Job Address ;i qR <br /> U S� 1( uba'vision�Name <br /> Owner' Phone <br /> s Name ' S <br /> Contractor's`Nam L_E L License No. Phone IM, a : � <br /> 4 _ <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT [ DESTRUCTION <br /> J <br /> PUMP INSTALLATION SYSTEM REPRIR OTHER—(J <br /> DISTANCE TO_NEAREST:�SEPTIC;TANK `` SEWER`LINES DISPOSAL'FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation <br /> Domestic/Private EJ Gravel Pack Tracy .- Dia.. of Well Casirg <br /> Public G Other Delta .Type of Casing <br /> Irrigation 'Approx. Eastern <br /> fCathodic Protection Depth _ Specifications r <br /> I F Depth of Grout Seal OQ <br /> Geophysical e <br /> Type of Grout <br /> ❑Other, ^..-.-er <br /> s Surface,Seal Installed by <br /> Repair Work Done G Type of Pump H.P. y State Work Done <br /> Well' Destruction L] Well Diameter —Sealing-Materi.al-,(top 50') _ <br /> Depth Filler Material (Below 50') <br /> Y - Y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will server Residence _ Commercials Other <br /> WumD`er of Ti i n g units: Number of bedrooms Lot size 0 0 <br /> Character of soil to a depth of 3 feet: C] , Water table depth come <br /> SEPTIC TANK Type/Mfg �' Capacity V d No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal V <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line 1 <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines v lJ Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE'PITS Depth _- _ Size Ncember I <br /> SUMPS �� Distance to nearest: Well Foundation -'" Property Line <br /> , . n <br /> D15P05AL PONDS---.<,«*..E_I <br /> I hereby certify that I have .prepared th's 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 fallowing: "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 /> thi it is i I shall en vy persons subject to workman's compensation laws of California." <br /> i The applica t cal f al e re ins ctions. Complete rowing o reverse si /Q r, + <br /> Signe Ti e: Date: <br /> E ONLY <br /> Application Accepted by Area/ D _ 5tk _466-6781, <br /> Oinal <br /> ional Comments: Lodi 369-3621 <br /> X0 4r Grout Inspe by Date � Manteca 823-7104 <br /> llt)6 Inspection by Date __LDL e�--�r2 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services I601'�t4azWPL5 Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0, <br /> INFalO <br /> {° 4 �}-}—_ � 10/82 500 <br /> . EH 13-24= REV.X10/.82 y L "�� <br /> =14-z6 <br />