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1 <br /> C. <br /> APPLICATION FOR PER.;; <br /> SAN JOAQLIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. I ] <br /> Telephone (209) 466-6781CiL- <br /> 3, 3 <br /> DATE ISSUED ( } 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 the San Joaquin Local Health District. <br /> Job Address &AVX:T!_r_,2_4Q Subdivision Name 1W • <br /> Owner's Name <Hpggyeddress D tA, . 4414, V > <br /> Contractor's Name ¢ LIJiense No. r„lJ r( j Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL `WELL REPLACEMENT DESTRUCTION U W UO <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE,WELL OTHER WELL PITS/SUMPS .F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I�findustrial U Open Bottom E] Manteca Dia. of Well Excavation <br /> mestic/Privates <br /> D Gravel Pack E] Tracy Dia. of Well Casing C.a r � <br /> ❑ Public F-1OtherDelta <br /> Type of Casing !✓!�� <br /> U Irrigation Approx. Eastern Specifications ' <br /> �JCathodic Protection Depth <br /> Geophysical Depth of Grout Seal <br /> Type of Grout <br /> U Dther � S n <br /> Surface Seal Installed by � <br /> r i l!V' W <br /> Repair Work Done Type of Pump �G d3f►vE H.P. ! State Work Done co <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') w — <br /> Depth Filler Material (Below 50') t/ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION_ J REPAIR/ADDITION j 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 D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest Well Foundation Property Line J <br /> DESTRUCTION <br /> LEACHING EINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line v <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CI <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 fallowing: "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 /> ractor's hiring or sub-contracting signature certifies the following: I certify that in the performance of the work for which <br /> th's ermit is issued, I shall emp persons subject to workman's compensation laws of California." <br /> Thtort ca a r ui d in ections. Complete drawing on reverse side. <br /> S' Title: Date: 11- 7 <br /> 0 PART USE ONLY <br /> n Accepted by Area f <br /> Comments: g p [� Lodi 369-3621 <br /> ut Inspection by Date - `����' Mantec 3-7104 <br /> Final Inspection by Date 3_, p� Tracy 835-6385 <br /> Applicant - Return all copies o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> £H 13-24 REV. 10/82 0/82 500 <br /> 14-26 � VJ tJ <br /> I <br />