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T ' <br /> k� <br /> APPLICATION FOR PERMIT <br /> SAN ,iCAQUiN LOCAL HEALTH DISTRICT <br /> 1601tE. HAZELTON AVE., STOCKTON, CA PERMIT NO. $ 0 T <br /> . ' F '.Telephone (209) 466-6781 <br /> DATE ISSUED �- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i <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 haji Joaouin Local Health District. ] <br /> Job Address ! Subdivision Name <br /> Owner's' Name dress Phone <br /> Contractor's Name icense No. Phone <br /> Tv rJ <br /> TYPF OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION { ..; t 1� ,' <br /> PUMP INSTALLATION F-1SYSTEM REPAIR `A L p, `OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Uv <br /> 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> CA <br /> INTENDED USE, I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial i ! ❑ Open�Bo•ttom -[;].Manteca. _ .. , , -_Oia._of..Weil Excavation <br /> I� LJ Domestic/Private [] Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public 1 Other Q Delta Type_of Casing <br /> Irrigation Approx.' Eastern Specifications <br /> Cathodic Protection Depth <br /> � Depth of Grout Seal <br /> Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> Repair Work Done FJ Type of Pump,- H,P.— - _ _ State Work-Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth — Filler Material (Below 50') r/} <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION Ej REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> Aberavailablewithin 200 feet.)Installation''will serve: ResidencCommercial OtherNumber of living units: 7 Nuof bedrooms Lot size <br /> Character of-soil to a depth of 0 feet: Water ytabRle;depth <br /> k SEPTIC TANK ❑ Type/Mfg Capacity ''No Compartments I/� <br /> `r PKG. TREATMENT PLT. F-1 Type/Mfg Capacity Method of Disposal V <br /> 7 SEWAGE SYSTEM Ei Distanc! to nearest: Well Foundation Property Line <br /> A DESTRUCTION <br /> LEACHING LINE No. & Length of lines Total length/size I ' <br /> FILTER BED Distance to nearest:' Well oundation Property Line <br /> SEEPAGE PITS j Depth ( Size Number <br /> SUMPS �� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that 1 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 workmang compensation laws of California." <br /> Contractor's'hi ring 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, ust 1 for all re d inspection , Complete dr Ing on reverse side. <br /> Signed X <br /> Title: Date: <br /> F DEP T ENT USE ONL Stk 466-678 <br /> Application Accepted by _ /G/ = _ AreaG5 <br /> Lodi 369-3621 <br /> Additional Comments: [� <br /> Pit or Grout Inspection,by <br /> Date �s" )"G�_ ] Manteca 823-7104 <br /> DateTracy 835-6385 <br /> w Final Inspection by <br /> �-Applicant - Return all copies to: Environmertal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 <br /> FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO p $ ^�( <br /> 10/82 500 <br /> r EH 13-24 REV, 10/82 <br /> 14-26 <br />