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APPLICATION FOR PERMIT <br /> SAN JDAQUiN LOCAL HEALTH DISTRICT <br /> k 1601 E. HAZELTON AVE., STOCKTUN, CA PERMIT NO. - <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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. the San Joaquin Local Health District, <br /> Job Address 4 �tSubdivision <br /> /�Name <br /> Owner's Name LV Address 74 VI 6.— Phone <br /> Contracto's Name `� fjl.� 1Lti License No. C3 <br /> Phone �t..l <br /> TYPE OF WELL/PUMP WORK: NEW�WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U {� <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open`Bottom ❑ Manteca Dia, of Well Excavation <br /> Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public <br /> J Other � Delta <br /> L i Irrigation Type of Casing <br /> Approx. � Eastern <br /> Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> J other Type of Grout <br /> QD � Surface Seal Installed by <br /> Repair Work Done f Type of Pump .L�t� H.P. , State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth I Filler Material (Below 501) j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is d j <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 J Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal i <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Li ~� <br /> DESTRUCTION ❑ # Line <br /> # <br /> LEACHING LINE Na, & Len'th of lines € <br /> U 9 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` <br /> 1 <br /> SEEPAGE PITS Cj Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <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 /> permit 1s issued, I shall not employ any person in such manner as to become subject to workmant 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 mu te 11 for all required inspections. Complete d in on reverse side. <br /> Signed X 1f 'l�t � Title: i► Date: <br /> TRTMENT USE ONLY t <br /> Application Accepted by FO z /_ Area J Stk 466-6781 <br /> Additional Comments: Lodi 369-3521 <br /> Pit or Grout Inspece-DUE <br /> Date Manteca 823-7104 <br /> Final Inspection by Date L Tracy 835-6385 <br /> Applicant - Return all copental Health Permit/Services 1601 L. Haz ton Ave., P.O. Box 2009, Stk:, CA 95201 <br /> k <br /> FEL BASE .AAMOUNT REMITTED RECEIVED 8Y DATE PERMIT N0, <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />