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APPLICATION FOw PE I, ; <br /> SAN JOAQbik LOCAL HEALTH u:STRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 _ <br /> f, <br /> f PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED <br /> i (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.Regulatiions of the San Joaouin Local Health District. hI <br /> Job Address ZM _04gag� ! ���_ Subdivision Name <br /> Owner's Named =S1 Address Phone C�1 <br /> Contractor's Name License No. <br /> Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> I PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SJMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IJIndustrial U Open Bottom Manteca Dia. of Well Excavation <br /> F <br /> jJ Domestic/Private Gravel Pack U Tracy Dia. of Well Casing <br /> Public Other Delta <br /> LjIrrigation Type of Casing <br /> Approx. � Eastern <br /> [Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> U Other Type of Grout <br />` Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done N <br /> Well Destruction U Well Diameter Sealing Material (top 501) ''Lq <br /> Depth Filler Material (below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve Residence Commercial Other available within 200 feet.) <br /> Number of iiving units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Cj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal 0 <br /> SEWAGE SYSTEM tx Distance t earest: Well .�- Foun ' n f ro ert L'ne �` <br /> DESTRUCTION P y �. <br /> LEACHING L[NEt LJ No.,& Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Cine —I <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS L—� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> 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 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 workmanIs compensation laws of California." <br /> Contractor's ring or sub-contracting signa ure certifies the following: "I certify that in the performance of the work for which <br /> this permit issued, -I shall employ"per subject to workman's compensation laws of California." <br /> The app lXCI 1 fo 11 require/44 'nns. Comp1 on reverse side. <br /> Signed X Title: <br /> Date: <br /> R ARTM USE ONLY <br /> Application Accepted by , G� � Area 45 Stk66-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection b Date a Manteca 823-7104 <br /> Final Inspection b Date L Tracy 835-6385 <br /> Applicant -.Return a c es to; -Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95202 <br /> FEE BASE AMOUNT DUE ' AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 j <br />