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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 <br /> Telephone (209) 466-6781 DATE ISSUED-- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br /> A <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 madelin compliance with San Joaquin County Ordinance No. 545 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations <br /> �Off the San Joaquin Local Health District. I <br /> Job Address 14 Subdivision Name <br /> j Address .� Phone <br /> Owner's Name <br /> License No. Phone 4166- <br /> / Q � <br /> Contractor's Name /ry�ISI+ <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR I] OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK DISPOSAL FLO. PROP. LINE <br /> I SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial U Open Bottom Manteca <br /> Dia. of Well Excavation <br /> U Domestic/Private E]GravelPack Tracy Dia. of Well Casing <br /> F .4 <br /> Public [—I Othert Delta Type of Casing <br /> V Irrigation Approx. Eastern Specifications J <br /> Cathodic Protection Depth <br /> Depth of Grout Seal } <br /> Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> Type of Pumpi. State Work Done <br /> Repair Work Done FJ_ TYp A. <br /> Sealing Material (top 50') — <br /> Well Destruction U Well Diamete* 9 <br /> Depth Filler Material (Below 50') <br /> ubliTYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION {No septic tank or seepage p'availableed if withinu200cfeet.) is <br /> Installation will serve: Residence _K Commercial _ Other <br /> Number of living units:lNumber of bedrooms � Lot size <br /> l Water table depth 1100,47 <br /> Character of soil to a depth ofJ! feet: No. Compartments <br /> SEPTIC TANK F_[ Type/Mfg Capacity <br /> Capacity Method of Disposal � <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Property Line.: <br /> SEWAGE SYSTEM Distant4 to nearest: Well Foundation <br /> DESTRUCTION '�+ X <br /> Total length/size <br /> LEACHING LINE No. & Length of lines f 7� �p <br /> .FILTER BED Distance to nearest: Well/ <br /> Foundation Property Line . <br /> Size Number <br /> Depth i <br /> SEEPAGE PITS p Property Line <br /> SUMPS �� Distance to nearest: Well Foundation <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 ctifies thesucfollowinmanner gs to became subiectthat ntohworkmaniscompensationwlawsfof California." <br /> permit is issued, I shall not employ any person <br /> Contractor's hiring or sub-contracting siaturubjectltoeworkman�slcompensationowing: 111 rlaws ofaCaliforniaerfvrmance of the work for which <br /> this permit is issued, I shall employ persons <br /> re spe tions. Complete draw in n everse <br /> The applicant must cal for all requiide. pate: <br /> Signed X� Title: r <br /> k FDR' E TME�e �lONLY ' 3 5tk 466-67$1 <br /> Area —�_,_� <br /> Application Accepted by Lodi 369-3621 <br /> Additional Comments: A Date Manteca 823-7104 <br /> - <br /> Pit or Grout Inspection by Tracy 835-6385 <br /> Date <br /> Final Inspection by <br /> Applicant - Return all copies nvironmentaI Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95 <br /> tPERMIT'NO. <br /> { DATE <br /> F�11E BASE AMOUNT DUE AMOUNT REMITTED � RECEIVED $Y <br /> } � s b <br /> 16/82 500 <br /> EH 13-24 REV. 10/82 <br /> l 14-26 <br />