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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I 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 ' <br /> i3 5 6. . <br /> 5.i��2:7# Subdivision Name <br /> Owner's Name _ha ZA_CT LA ,QpP Address 7 c' Phone <br /> Contractor's Name 4,1, �`�1� �, License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION E] SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> U Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing <br /> Public Ej Other Delta <br /> Ljlrrigation Type of Casing <br /> Approx. � Eastern <br /> Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> U Other Type of Grout <br /> Surface Seal Installed by +' <br /> Repair Work Done Q Type of Pump H.P. .State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION LV (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence _ Commercial Aefl Other available within 200 feet,} <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water,,table depth <br /> C1 Type/Mf <br /> g Capacity No. Compartments ' -- <br /> PKG. TREATMENT PLT. Type/Mfg Capacity ;-—.Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line rjl <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines Total length/size ez—p— <br /> FILTER BED Distance to nearest: Well Foundation ! Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS l___I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS E <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 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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: _ _�,� �'—�� <br /> FOR P RTMENT USE ONLY ❑ <br /> Application Accepted by Area Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection oky Date Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Bax 2009, St k., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DPERMIT N0. <br /> INFO <br /> ;LL <br /> S <br /> EH 13-24 REV. 10/82 <br /> I4-26 10182 500 <br />