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i a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 ' <br /> GATE ISSUED <br /> PERMIT EXPIRES i 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 theSanJoaquin Local Health District. <br /> Job Address 1p3& /C•t.itt4 , Subdivision Name <br /> Owner's Namek Address , 6 L moist Phone <br /> Contractor's Name ;04 cense No. Phone <br /> TYPE OF WELL/PUMP WORK: NEVI WELL WELL REPLACEMENT F-1 DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER L—I S` <br /> DISTANCE TO NEAREST: SEPTIC TANK /Qp%�1 SEWER LINES /p, y � DISPOSAL FLD. ., PROP. LINE <br /> FOUNDATION AGRICULTURE -WELL. OTHER WELL ?ITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C"ONSTRUCTION SPECIFICATIONS <br /> Industrial pen Bottom Manteca N Dia. of Well Excavation <br /> L_I Domestic/Private ❑ Gravel Pack ❑Tracy Dia, of Well Casing__ <br /> Public Other [] Delta Type of Casing ls&sd <br /> rrigation Approx. [] Eastern Specifications % <br /> Cathodic Protection Depth <br /> ❑ iDepth of Grout Seal" <br /> Geophysical Type of Grout ' <br /> Other Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter - E C� Sealing Material {top 50') — <br /> Depth / r Filler Material (Below,50') <br /> TYPE OF SEPTIC WORK 1°'NEW�INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation-will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. [] Type/Mfg Capacity.' Method of Disposal <br /> SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CI <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 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, 1 shall employ persons subject to workman's cogpensation laws of California." <br /> The app lic nt st call for alp equired inspections. Complete dra g an raver"se side. <br /> e Title: Date: & d <br /> Signed X <br /> FO ARTMENT USE ONLY <br /> Application Accepted by J7143 Area f Stk 466-6781 <br /> Additional Comments: k.Lodi 369-3621 <br /> Pit or Grout Inspection Date U Manteca 823-7104 <br /> Final Inspection by Date �/ Tracy 835-6385 <br /> Applicant - Return all copies ronmental Health Permit/Services 16 E. azelton Rve., P Box 2009, St k., CA 95201 <br /> =�- <br /> 77 <br /> AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO 3 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />