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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 2 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. J <br /> Telephone (209) 466-5781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE_ISSUED DATE III ISSUED <br /> (Complete,in Triplicate) ; <br /> rx <br /> f 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.'I1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Namei Address QM : µ. -«• Phone'. <br /> Contractor's Name A — License No. Phonegl,�G �,cG <br /> JS <br /> } TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ �JJ <br /> ' PUMP INSTALLATION 0 SYSTEM REPAIR OTHER f I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE -�?N <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> 4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> FJ Industrial <br /> U Open Bottom Manteca Dia. of Well Excavation <br /> jJ Domestic/Private E]Gravel Pack Tracy Dia. of Well Casing <br /> ❑ Public F-jOther Delta <br /> Irrigation Type of Casing <br /> Li 9 Approx. Eastern Specifications <br /> s F_�Cathodic Protection Depth <br /> k �Geophysical <br /> Depth of Grout Seal <br /> Other Type of Grout <br /> Surface Seal Installed by I n <br /> Repair Work Done [J Type of Pump H.P. State Work Done V L <br /> r Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') r � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if purblic sewer is <br /> Installation will serve: Residence _*,-�Commercial _ Other available within,i200 feet.) <br /> Number of living units: _ Number of bedrooms Lot size -y C_/?e S <br /> I Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Ej Type/Mfg Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Ei Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size M <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth c2 5- Size c7 G Number <br /> SUMPS U Distance to nearest: Well fj0..L Foundation J 0 Property Line ,j'f <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 /> t permit is issued, 1 shall not employ any person in such manner as to become subject to workmant compensation laws of California." <br /> IIf Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance offthe work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Thea licon m <br /> pp rca for required in ctio Complete drawing on reverse side. <br /> Signed X Title: Date:, '40 <br /> MENT USE ONLY <br /> DEP T <br /> Application Accepted by _ "/1. Area 617— S t k 466-6781 <br /> Additional Comments: [] Lodi 369-3621 <br /> Pit or Grout Inspection by Date / ��j L� Manteca 823-7104 <br /> Final Inspection by /� _ Date L{ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95202 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO " <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 r <br /> f ,r <br />