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t � t <br /> APPLICATION FOR PERMIT <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. g LJ_ S 1 <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSU%-- <br /> (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 <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 <br /> the San 01JoaQu <br /> A0 11/z/ in Local Health District. <br /> Job Address �zf T/ �j (Gcti L� (d <br /> Owner's Name J? Address c��/car/ / ;,,' yam,.. Phone Y13 125�3 <br /> Contractor's Name I� License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION [] <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -a <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> I71 Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> LA <br /> I Public F-1 Other Delta Type of Casing <br /> V Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal 3 <br /> 17 Geophysical Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done EJType of Pump .lR' H.P. State Work DoneC- G�lt�+y- t R <br /> Well Destruction F-J Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION [J_ (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. [J Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED E] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <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 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 employ persons subject to workman's compensation laws of California." <br /> The applicant must call or required inspections. Complete draw' on(reverse side. <br /> Signed X�/_Qi� �r� c� Title: j '1 Date: <br /> F D kRTMEN USE ONLY Area �1 0./ Std <br /> ❑ <br /> Application Accepted by 466-6781 <br /> Additional Comments: [] Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all copi nvironmental Health Permit/Services 1601 E. Haz lton Ave., P.O. Box 2009, St k., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 377a'7 <br />