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r.� <br /> A <br /> r <br /> APPLICATION FOR PfRPI`T <br /> SAN JOA.QL-i" LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, J—1�7 <br /> Telephone (209) 466-6781 <br /> j <br /> PERMIT EXPIRES 14YEAR FROM DATE ISSUED DATE ISSUED 3 (} <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 Regul`i y ns of the San Joaquin .Local Health District. <br /> Joh Address 3 ,- . Subdivision Name <br /> Owner's Name 14 h ddressPhone <br /> I Contractor's Name — icense No. b Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER w <br /> IDISTANCE To NEAREST: SEPTIC TANK ' <br /> I �_�....--.__.. _ ._SEWER,LINES i. �'`_; i..: DISPOSAL --- <br /> .�-- TPROP .r LINE_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS q� <br /> IN INTENDED USE <br /> TYKE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> JJ Industrial U Open Bottom Manteca Dia, of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia, of Well Casing <br /> Public fj Other Delta <br /> V <br /> Irrigation •9 Approx. EJ Eastern Type of Casing <br /> Cathodic Protection Depth Specifications <br /> L_J Geophysical Depth of Grout Seal = <br /> LJ Other . _Type of Grout <br /> e Surface Seal Installed by t <br /> ;Repair Work Done Type of Pump } H.P. State•Work Done L� <br /> Well Destruction U Well Diameter Sealing Material (top 50`) <br /> E t <br /> I Depth r Fi11er"Material (Below 50') <br /> # TYPE OF SEPTIC WORK: NEW INSTALLATION J REPAIR/,.ADDITION LJ (No 'septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> ]nstallatinn will serve: sidence Commercial `s Other ' <br /> a s <br /> Number of `living unifs:— �-s Number of bedrooms Lot size <br /> Character of soil to.a depth of 3 feet: IsWater table depth <br /> SEPTIC TANK b' 5E <br /> Type/Mfg �2 +E Ca y _- No. Compartments <br /> PKG. TREATMENT PLT.. " Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEMS . Distance to nearest: Well �O� Foundati.on_.�.___._.,.�_Property-Line ' <br /> DESTRUCTION ❑ ` �- <br /> 1 LEACHING LINE"I" No. &,Length of T:inesr Total length/sizeoil [� <br /> • FILTER BED , Distance to nearest: Well d .i ourdatian Property Line Fr <br /> SEEPAGE PITS Depth Size Number ; <br /> 'ti SUMPS <br /> LJ Distance to nearest: Well Foundation 'Property Line <br /> ,w DISPOSAL PONDS <br /> � 4 <br /> I hereby certify!that YI have prepared this application and that the work will be done in accordance with San Joaquin county i <br /> ,",ordinak es, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this. I <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 /> er7mft,,is issuI shall mploy persons subject to workman's comrpensation laws of California.he a u t ca 1 f al equired inspections, Complete awing o reverse de. , <br /> Signed Title: Date: <br /> I FO DEPARTMENT USE ONLY I <br /> Application AcceptAby Area Stk 466-5781 <br /> Additional CommentQ f T L �.r1w �] Lodi 369-3621 <br /> Pit or Grout [nspeDate Manteca 823-7104Final Inspection bDate Tracy 835-6355 <br /> Replicant - Return al hccEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ' <br /> f <br /> INFO 4 <br /> EW 13-24REV:10%82 1D/.82_500, _ ,,., <br /> 14-26 <br /> i <br />