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" APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH 31STRICT ^j <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local HealthDistrict 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 alth District. Vr <br /> Job Address ":,5?. Ci I •t.[I Subdivision Name <br /> Owner's Name Address 3. �/ r Phone <br /> j Contractor's Name License No. Phone 41e ;? <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK 4 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack U Tracy Dia, of Well Casing <br /> 17 Public CJ Other ❑ Delta 1 <br /> Typeof Casing <br /> V Irrigation Approx. Eastern <br /> Cathodic Protection Depth Specifications <br /> L-1 Geophysical Depth of Grout Seal <br /> L]Other Type of Grout Q]� <br /> F 1 Surface Seal Installed by <br /> Repair Work Done EJ Type of Pump!'. HP <br /> . , , State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> ;Iavailable within 200 feet.) . <br /> Installation will serve: Residence 1k. Commercial _ Other <br /> Number of living units: _ Number of bedrooms .2� Lot size <br /> r <br /> Character of soil to a depth of'3 feet: Water table depth <br /> SEPTIC TANK Type/Mfgl� w� Capacity �_ No. Compartments Z <br /> PKG. TREATMENT PLT. Type/Mfg + Capacity Method of Disposal '} <br /> SEWAGE SYSTEM Distance to nearest: Wells Foundation /P Property Line yj <br /> DESTRUCTION <br /> LEACHING LINE ' No. & Length of lines Total length/size �� <br /> FILTER BED Distancelto nearest: Well ��(/ � Foundation /Q � Property Line <br /> .� <br /> SEEPAGE PITS ( Depth Size 3 rs Number f _ <br /> r ? <br /> SUMPS J Distance to nearest: Well�rl tt Foundation e"Q r Property Line <br /> I <br /> DISPOSAL PONDS � r <br /> T ; I <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:ard 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." 1 <br /> Contractor's hiring or sub-contracting signature certifies,the following: "I certify that in the performance of the work for which I <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." �l <br /> The applicant�t/ s call for all e fired i pections. Complete drawin on reve a side. <br /> Signed X � � . Title: -- - Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by t Area Stk 466-6781 <br /> Additional Comments: ?R Lodi 369-3621 <br /> Pit or Grout Inspection by t' Date Manteca 823-7104 <br /> Final Inspection by ��?' Date Ar Tracy 835-6385 <br /> Applicant —Return all copies to:, Environmental Health Permit/Services 1601 E. Hazelton Avc!, P.O. Box 2009, Stk., CA 95201 <br /> FEEBASE AMOUNT, DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO '= <br /> 73-oq� <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br /> x <br />