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a � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � <br /> ! Telephone (209) 466-6781 ° DATE ISSUFD <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 cam_ <br /> described. This application is made1in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump W <br /> and the Rules and Regulations of thetSan Joaquin Local Health District. <br /> Job Address 11409 . �.f�st� ADS� Subdivision Name 4 <br /> Owner's Name I Address Phone 3Z l <br /> �i�sl� s License No. Phone <br /> Contractor's Name <br /> TYPE OF WELL/PUMP WORK: NEW.WELL WELL REPLACEMENT DESTRUCTION <br /> -..PUMP INSTALLATION � SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION.- AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t} <br /> �� Industrial U Open Bottom Manteca Dia. of Well Excavation { <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public [1 Other ❑ Delta Type of Casing <br /> V Irrigation Approx. Eastern Specifications - t <br /> ❑ Cathodic Protection Depth <br /> Depth of Grout seal <br /> GeophysicalType of Grout E <br /> U Other Surface Seal Installed by <br /> Repair Work Done Type of Pump ; H.P. State Work Done <br /> Well Destruction U ;Well Diameter} Sealing Material (top 50') <br /> Depth I� Filler Material (Below 501) <br /> i. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial i Other <br />. .� Number of living units: ' Number of bedrooms Lot size <br /> Character of soil to a depth of-3 feet: �/9A <br /> —� Water table depth <br />` SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> I Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity <br /> SEWAGE SYSTEM Distance.to nearest: Well Foundation Property Cine <br />{ DESTRUCTION I d <br /> LEACHING LINE No. & Length of lines d Total length/size <br /> r Property Line <br /> FILTER BED �_ Foundation <br /> Distance to nearest: Well �9 <br /> Number <br /> r SEEPAGE PITS ❑ Depth Size Sj <br /> Distance to nearest: Well 404 Foundation _ Property Line_ <br /> SUMPS � , e <br /> � . <br /> DISPOSAL PONDS <br /> F <br /> E I hereby certify that 1 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 /> I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> Perm is issue I shall not employ any person in such manner as to became subject to workman compensation laws, of California." <br /> Contractor's r ng or subcontracting sign re certifies he following: "I certify that in the performance of the work for which <br /> i <br /> this permi s sued, I shal employ per s subject to wo man's mpensation laws of California." �} <br /> The appli t — 11 for 1 require naq spe ons. 10 <br /> Comple e d on reverse side. <br /> Signed <br /> Title: Date: J <br /> DEPRRTMENT USE ONLY Stk 466-fi781 <br /> Application Accepted b " Area __fr� <br /> Edi 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> Pit or Grout Inspection by Date <br /> Final Inspection by <br /> Date �7- � Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE <br /> PERMIT N0. <br /> k d � INFO � <br /> 5 �a L'1 S o� "!'Y1 �- <br /> k aye 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />