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,;. <br /> is <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT � �� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Q <br /> ' Telephone (209) 466-6781 DATE ISSUE <br /> 1) <br /> F <br /> PERMIT EXPIRES i'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> an Joaquin 1.o cal Health District for a permit to construct and,/or install the work herein <br /> Application is hereby made to the'S <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> f and the Rules and Regulati n� of the San Joaquin Loc 1 alth 0istrict. x <br />[` Job Address ,ubbdiv`ision Name <br /> Address �ir7 Phone Z" <br /> Owner's Name Phone <br /> Contractor's Name License <br /> TYPE OF WELL/PUMP WORK: NEWELL L] WELL REPLACEMENT DESTRUCTION <br /> W � oC1 <br /> PUMP INSTALOTHERLRTION � SYSTEM REPAIR L] U <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES PITS/SUMPS <br /> FOUNDATION <br /> it AGRICULTURE WELL OTHER WELL <br /> t <br /> INTENDED USE TYPE{OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J J Industrial U Opel Bottom ❑ Manteca <br /> Dia, of Well Excavation i <br /> 1 L 1 Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public OtherDelta <br /> ❑ Type of Casing <br /> [j Irrigation lApprox. E Eastern Specifications <br /> Cathodic Protection Depth Depth of Grout Seal <br /> Geophysical Type of Grout <br /> U Other h ` •' Surface Seal Installed byl ' <br /> 4 } <br /> Repair Work Dane E] H P Type of Pump State Work Done Vs <br /> Well Destruction F-1 Wei l Diameter Sealing Material (top 50') — <br /> j.` Depth Filler Material (Below 50') 1l <br /> FVQ <br /> LATION L� REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTAL <br /> 1 available within 200 feet.) <br /> l Installation will serve: Residence _)4 Commercial Other <br /> Number of bedrooms Lat size _Z;?_Q` f <br /> Number of living units: Water table depth .11 a <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> �F= SEPTIC TANK F-1Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity <br /> PropertyLine <br /> ' SEWAGE SYSTEM Distance to nearest: Well Foundation <br /> DESTRUCTION <br /> No. <br /> LEACHING LINE � 9& Lenth of lines J# Total len gth/size <br /> `,w ` ♦ Property Line "" <br /> FILTER BED Distance to nearest: Well pa Foundation <br /> ySize Number �.� <br /> `T SEEPAGE PITS Depth.[ size <br /> '>_' SUMPS U <br /> Distance to nearest: Well — Foundation *2�� Property Line /�� <br /> DISPOSAL PONDS <br /> application and that the work will be done in accordance with San Joaquin county <br /> I hereby certify that I have prepared this appLocal <br /> ordinances, state-laws, and rules and regulations of the San Joaquin"I Health <br /> insthecperformance of the work for which this <br /> Home owner or licensed agent's signature certifies the following: <br /> I: permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California."i <br /> Contractor's ring or sub-contracting ersonsurebject�toeworkman�sl�ompensationrlaws ofaCalifornit in th aerformance of the work for which <br /> this permit issued, 1 shall employ p <br /> The applic t call fo 11 re r, in ction Comple a dr Ing an reverse side. Date; <br /> Signed X Title: <br /> �� FO PARTME J15E ONLY G 4, �� g• Stk 466-6781 <br /> Application Accepted b 4 Area <br /> Lodi 369-3621 <br /> r Additional Comments: Manteca 823-7104 <br /> � <br /> ! Pit or Grout Inspection by 4 kJ a a Date Date 7—/- 3 L�i T 3 �7 .Tracy 835-6385 <br /> Final Inspection by <br /> I Applicant - Return all copiesC o:, nvironmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> DATE PERMIT NO, <br /> FEE BASE AMOUNT DUE RMOUNT REMITTED RECEIVED BY �Q <br /> m <br /> INFO i u ,— <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />