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F <br /> ' APPLICATION FOR PERMIT { <br /> SAN JOAQUi': LOCAL HEALTH DISTRICT <br /> PERMIT NO. <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6181 PATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. <br /> (Complete in Triplicate) <br /> E <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. 549 for sewage or No. 1862 for:well/pump <br /> and the Rules and Regulations of the-San Joaquin Local Health District. <br /> Job Address z ` Subdivision Name <br /> Address -1-- Phone <br /> Owner's Name _ <br /> Contractor's Name <br /> License Na. Phone / <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION r ,1 <br /> PUMP INSTALLATION SYSTEM REPAIR �. OTHER LI PROP. LINE <br /> /fir 1lN <br /> DISTANCE TO NEAREST: SEPTIC TANK i��[](<+ SEWER LINES �Q { = DISPOSAL FLD.� Q �f 1_- l <br /> AGRICULTURE WELL OTHER WELL SQ PITS/SUMPS 0 <br /> FOUNDATION r� <br /> INTENDED USE TYPE OF WELL YPROBLEMCONSTRUCTION SPECIFICATIONSIndustrial Open Bottom d Dia. of Well Excavation <br /> Donestic/Private Gravel-Pack Dia. of Well Casing <br /> Public O-Other' Type of Casing <br /> IM Irrigation `�jyy ' Approx. Specifications <br /> Cathodic Protection v. Depth <br /> Depth of Grout Seal <br /> ❑GeophysicalType of Grout 1 <br /> y U Other y. tr 'Surface Seal Installed by <br /> Repair Work Done G Type of Pump H.P. State Work hone <br /> y <br /> Well Destruction U Well Diameter Sealing Material (top 501)- — <br /> r Depth Filler Material (Below 50') <br /> r <br /> i <br /> sewer <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage p'availableewithid if nu200cfeet.) 3s <br /> Installation will serve: Residence _ Commercial _ Other <br /> sewer <br /> Lot size <br /> Number of living units: ;l Number of bedrooms Water table depth <br /> Character of soil to a depth of'3 feet: <br /> ,i No. Compartments <br /> SEPTIC TANK Ej Type/Mfgi Capacity <br /> Type/Mfg y Method of Disposal <br /> PKG. TREATMENT PLT, � j Capacity <br /> t <br /> SEWAGE SYSTEM � Distance to nearest: Well foundation Property Line <br /> DESTRUCTION �l <br /> f LEACHING LINE U No. & Length of lines Total length/size <br /> Distance to nearest: Well Foundation Property Line <br /> FILTER BED ,t <br /> SEEPAGE PITS Depth ;} Size Number <br /> SUMPS LJ Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS �1e,.m& Big." <br /> hhereby 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 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 fairing or sub-contracting signature certifies the following: "I Certify that in the performance of the work for which <br /> -this permit is issued, 1 sha emp oy ersons subject to workman's compensation laws of California." <br /> The applic ust cal for 11 qu red inspections. Complete drawing on re erse side. pate: <br /> 1Stgned _.,Title:.- - AL <br /> } i DEPARTM T USE ONLY OS Stk 466-6781 <br /> _' <br /> Application' Accepted'by Area Lodi 369-3621 <br /> Additional Comments: ` Manteca 823-7104 <br /> Pit or Grout Inspection Date <br /> *� <br /> Date ,-.710"6 ❑ Tracy 835-6385 <br /> Final Inspection by - CA 95201 . <br /> 'Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltor Ave., P.O. Bax 2009, 5t k., <br /> DATE PERMIT NO. <br /> FEE BASF AMOUNT'IDUE AMOUNT REMITTED = a(T RECEIVED`BY _( <br /> INFD f GT X02 73"` <br /> EH 13-24 REV. 10/82 -Ar:_V Io/az goo. <br /> 14-26 <br /> f k <br />