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APPLICATION FOR PERMIT <br /> SAN JOAUUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.�?S_ l <br /> Telephone (209) 466-6781 DATE ISSUED r Y3 <br /> i <br /> 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 Regulatio of Van San Joaquin LocalHealth D'strict. <br /> Job Address +� �v♦v� <br /> Owner's Name Address Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION {❑ SYSTEM REPAIR ❑ OTHER Lj } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN€S DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS V v <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . �^ <br /> Industrial I U Open Bottom ❑Manteca Dia. of Well Excavation �) <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing <br /> ❑ Public 111 ❑Other ❑ Delta .Type.of Casing <br /> Approx.irrigation 1 A Eastern <br /> V 9 t PP ❑ Specifications <br /> Cathodic-Protection Depth <br /> hPtip <br /> ❑ � � Depth of Grout Seal <br /> ❑Geophysical t Type of Grout <br /> F-JOther 1 Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump N.P. State Work Done S! <br /> F4 <br /> Well Destruction ❑ Well Diameter. Sealing Material (top 50') <br /> p ) <br /> Depth '" Filler Material (Below'50') <br /> TF1REPAIR/.4DUITION (No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> available within 200 feet.) <br /> f 41 <br /> Installation will serve: Residence Commercial Other �y <br /> g _—F of�*re ooms /'"'A Lot size <br /> f Number of linin units: � �Num6er of bedrooms <br /> ,Character of soil to a depth of 3 feet: ' '+� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 1 Capacity r"i 1 V­0 Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg�. R F.ti Capacity Method of Disposal r <br /> SEWAGE SYSTEM ci Distance to nearest: Wellf, ! _ Foundation Property Line <br /> DESTRUCTION 1 <br /> ti LEACHING LINE No.I& Length of lines Total length/size <br /> ' FILTER BED ❑ Distance to nearest: Well i Foundation Property Line <br /> SEEPAGE PITS E) Dep4hl _ Size Number <br /> SUMPS E_l Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application4andkthat 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, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant us 11 for all ired insp t' ns. Complete" <br /> on reverse ide. - <br /> Signed x Title: /v�J Date: / <br /> FOR kltvT USE ONLY <br /> Application Accepted by Area 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection y Date ❑ Manteca 823-7104 <br /> Final Inspection by r Date { �� ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 4zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE `s'AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO fa 14 <br /> EH '13-24 REV. 10/82 Y l raj�i� 10/82 500 <br /> € 14-26 <br />