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I APPLICATION FCR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA f PERMIT NO. 3 - 7� <br /> Telephone (209)"466-6781 <br />" PERMIT EMPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> s <br /> J (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 lJc! <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, 03 <br /> Job Address embr Subdivis.ion Name <br /> Owner's Name 07L/ ; Address C <br /> 4p� Phone <br /> Contractor's Name -� - � � 7�_ <br /> iCense No. PhoneR'3 C �1 <br /> TYPE OF WELL/PUMP WORK: NEWIWELL 0 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 OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . <br /> 0 industrial LJ OpenBottom [] Manteca Dia. of Well Excavation <br /> F_Z1 Domestic/Private . E] Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public 's Other (] Del to <br /> Type of Casing <br /> Ljirrigation Approx. Eastern <br /> Specifications <br /> Cathodic Protection Depth <br /> Geophysical Depth of Grout Seal Id <br /> 17 Type-of Grout <br /> U Other <br /> d Surface\Seal Installed by <br /> Repair Work Done [K Type of Pump �►z.c ifs" H.P. �j State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') w <br /> Depth Filler Material (Below 50') 4 <br /> TYPE OF SEPTI£ WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or; seepage pit#permitted if public sewer is <br /> 1 <br /> Installation will serve: Residence _ Commercial _ Other available within 200 feet.) i <br /> Number of living units: Number of bedrooms Lot size 4 I� <br /> Character of soil to a depth of 3 feet: { Water table depth { <br /> SEPTIC TANK '�, p Type/Mfg Capacity No. Compartments <br /> a , .. <br /> —PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM f Distance to nearest: Well Foundation t Property`Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance .to nearest: Well Foundation t PropertyLine <br /> SEEPAGE PITS Depth : Size Number <br /> SUMPS a U Distance,to nearest: Well Foundation 'PropertyyLine <br /> DISPOSAL PONDS <br /> 94 <br /> �. i in.anon .n.�. ,.i.m.i.ir.n...• i.ni�m... <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance.pwith San Joaquin county <br /> ordinances,istate laws, and rules :'end regulations of the San Joaquin Local Health District. ; ­ a <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.emplb y persons subject to workman's compensation laws,of California." <br /> The appl* a mus call �forllrequired inspections. Complete drawing on reverseJsi'de. ( �� <br /> Signed X Title: Date:Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Area Q Stk 466-6781 <br /> Additional Comments: PCLodi 369-3621 <br /> Pit or Grout Inspection 4Date Manteca 823-7104 <br /> Final Inspection,by i Date ❑ Tracy 835-6385 <br /> Applicant Return al.] copie °,tq: . _Enviro ental Health Permit/Services 16011E, kielton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE" AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> Jr "!4, a <br /> t - <br /> EH 13-24 REV, 10/82 10/82 500 <br /> 14-26 <br />