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;r�el '''' 'I :;, ,t ,: <br />APPLICATION FOR PERMIT Fi to rim.ub i <br />SAN JOAQLiN LOCAL HEALTH DISTRI; 5 <br />1601 E. HAZELTON AVE., STOCKTON, CA' PERMIT NO. <br />Telephone (209) 456-6781 q <br />DATE ISSUED/ <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUE #, 'r <br />(Complete in Triplicate) *REAL H 06 s 1 <br />LT <br />Application is hereby made to the San Joaquin Local Health District for a permit to corstruct 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 Health District. <br />Job Address !taF_M a/. �pL/ � ��r RV . Subdivision Name <br />Owner's Name X 7?Z 4Cpor �1' 'Sa �� Address /it) Phone i- <br />Contractor's Name License No. Phone <br />TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br />PUMP INSTALLATION SYSTEM REPAIR OTHER U <br />DISTANCE TO NEAREST: SEPTIC TANK ;r /i rr. SEWER LINES DISPOSAL FLD..tr f Z42 PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />F-1 Industrial U Open Bottom Manteca Dia. of Well Excavation <br />U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing <br />17 Public [] Other ' Delta <br />Type of Casing <br />V Irrigation Approx. Eastern <br />[Cathodic Protection Depth Specifications <br />Depth of Grout Seat <br />0 Geophysical <br />Type of Grout <br />U Other Surface Seal Installed by <br />Repair Work Done EJ Type of Pump Xjh ri r, H.P. `� %��° State Work Done <br />Well Destruction U Well Diameter Sealing Material (top 50') <br />Depth Filler Material (Below 50') ,. <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence Commercial <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />SEPTIC TANK Type/Mfg <br />PKG. TREATMENT PLT. U Type/Mfg <br />SEWAGE SYSTEM Ei Distance to nearest: Well <br />DESTRUCTION <br />Other <br />Lot size <br />Capacity <br />Capacity <br />Foundation <br />_ Water table depth <br />No. Compartments <br />Method of Disposal <br />Property Line <br />M <br />iii <br />LEACHING LINE U No. & Length <br />of lines Total length/size <br />FILTER BED Distance to <br />nearest: Well Foundation Property Line <br />SEEPAGE PITS ❑ Depth <br />Size Number <br />= SUMPS`, Distance to <br />nearest: Well Foundation. Property - L-i-ne-. <br />, <br />DISPOSAL PONDS ❑ <br />I hereby certify that I have prepared <br />this application and that the work will be done in accordance with San Joaquin county <br />ordinances, state laws, and rules and <br />regulations of the San Joaquin Local Health District. <br />Home owner or licensed agent's signature <br />certifies the following: "I certify that in the performance of the work for which this <br />permit is issued, I Shall not employ any <br />person in such manner as to become subject to workman � compensation laws of California." <br />Contractor's hiring or sub -contracting <br />signature certifies the following: "I certify that in the performance of the work for which <br />this permit is issued, I shall employ <br />persons subject to workman's compensation laws of California." <br />G <br />The applicant must call for allrequired inspections. Complete drawing on reverse side. <br />Signed X ' <br />Title: A- Date: <br />�p� <br />7F3 <br />[ <br />Application Accepted by <br />EPARTME9 E ONLY <br />Area Stk 466-6781 <br />Additioral Comments: <br />Lodi 369-3621 <br />Pit or Grout Inspection by <br />Date Manteca 823-7104 <br />Final Inspection by <br />Date� L7Tracy 835-6385 <br />Applicant - Return all copies to: <br />iranmental Health Permit/Services 1 01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />FEE BASE AMOUNT DUE AMOUNT REMITTE RECEIVED BY DATE PERMIT NO. <br />INFO <br />EH 13-24 REV. 10/82 U 10/82 500 <br />14-26 <br />