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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH 'DISTRICT <br /> r 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 DATE ISSUED g <br /> PERMIT EXPIRES i YEAR FROM BATE ISSUED <br /> 1 , <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health'Ci strict 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]San Joaquin Local Health District. <br /> Job Address L f, 1 Subdivision Name <br /> Owner's Name Address Phone <br /> Contractor's Name V <br /> icense No. Phone Z <br /> TYPE OF WELL/PUMP WORK: NEWWELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION 71 SYSTEM REPAIR OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IJ industrial r_1 Open fBottom ]Manteca Dia. of Well Excavation <br /> U Domestic/Private E]Gravel Pack Tracy Dia, of Well Casing <br /> Public Other Delta Type of Casing <br /> Irrigation Approx. E] Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done 0 Type of PumpH.P. State Work Done <br /> Well Destruction ❑ Well Diameter 1 Sealing Material (top 50') <br /> DepthFiller Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage Pit permitted <br /> lable ifpublic <br /> thin 200fsewe)is <br /> avaInstallation will serve: Residence Commercial _ Other <br /> 9 �' Number <br /> Number of living units: {Jof bedrooms Lot size,.3 <br /> Water table depth <br /> Character of soil to a depth of,3 feet: j <br /> SEPTIC TANK Type/Mfg D F G Capacity I0 --- No. Compartments 2--_ <br /> PKG. TREATMENT PLT. Type/Mfg <br /> Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well { Foundation 1 roperty Line <br /> If DESTRUCTION Total length size p rl`f <br /> LEACHING LINE No. & Length of lines <br /> FILTER BED <br /> Distance.to nearest: Well _ Foundation _Z42_!_ Property Line d~l e <br /> Number <br /> SEEPAGE PITS Depth Size <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL'PONDS" CI <br /> 4 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. this <br /> es the i Home Owner or licensed agent's Signature cifiin suchFinanrernas to becomeysubjectthat ntohworrkmaon� compensation rmance of the wlaws fof California." <br /> permit <br /> permit is issued, I shall not employ any person <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for w is <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." . <br /> The applicant must call for all re aired inspections. Complete drawing an reverse si <br /> Signed X <br /> �'A Title: ate• <br /> n EPARTMENT USE ONLY Stk 466-fi781 <br /> Application Accepted by �C/r -� Area / <br /> I [� Lodi 369-3621 <br /> Additional Comments: anteca 823-7104 <br /> Pit or Grout Inspection by hate <br /> Final Inspection by <br /> Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies ironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> kPERMIT NO. <br /> kf FEE BASE AMOUNT ':DUE AMOUNT REMITTED RECEIVED BY DATE <br /> i. INFO <br /> fit } S3- <br /> �"Z 10/82 500 <br /> yEtw,1[3=24 REV. 10/82 0 f 'Ai, <br /> 1 Ai, <br /> 14-26 <br />