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I <br /> l <br /> APPLICATIONJOR_PERMIT <br /> SAN JOAQI;It; LOCAL HEALTH DISTRICT <br /> }, 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 / <br /> DATE ISSUED v r? IS <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ��Z 1 (Compl.ete in Triplicate) <br /> Application is hereby made to the SY Joa7uin 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 />'E <br /> and the.Rules uI tions of the San Joa in Local Health District. <br /> Job Address Subdivision.Name <br /> Owner's Name Address Phone <br /> Contractor's Name ense No. Phone <br /> TYPE OF WELL/PUMP WORK: T NEW WELL [] WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER FI pa <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial n ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> U Domestic/Private F7 Gravel Pack []Tracy Dia. of Well Casing <br /> 17 Public F-1 Other Delta Type of Casing <br /> Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Det o <br /> Depth f Grout Seal <br /> Geophysical k Type of Grout <br /> U Other } Surface Seal Installed by <br /> k Repair Work Done Type of Pump H.P. State Work Done <br /> well Destruction U Well Diameter ` Sealing Material (top 5O') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION' (No septic tank or eepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> p Installation will serve: Residence,i Commercial _ Other 6 Yw <br /> f Number of living units: Number of bedrooms Lot size , <br /> Character of soil toya depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg �,�n CSpaeity No. Compartments <br /> * Method of Disposal <br /> PKG. TREATMENT PLT. Type/Mfg Capacity <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation, _ _Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines _� /Lt Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line --4 <br /> SEEPAGE PITS Depth -_ Size Number <br /> SUMPS Distance tolnearest: Well Foundation PropArty Line <br /> - <br /> DISPOSAL PONDS ❑ " <br /> '1 hereby certify that I have prepared this application and-that the work will be done in accordance wi.th,San Joaquin county <br /> dinances, state laws, and ons o <br /> or rules and regulation's the.San Joaquin Local Health District. ' . <br /> ,Home owner or licensed agents-signature"certifies`the following: "'I cern"fy'that in_ahe performance-of the work for which this <br /> permit is issued':' i -sha )' <br /> .l '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 certif.ies the following::"I 'cer.tify,that in the performance of the work for which <br /> this permit is issued, I,.shall employ persons subject to. wdrkman's compensationyl"aws-of-Cal 'fo.rni"a.." <br /> The applicant us 11 fbr'aYT `quired inspectio —Complete drawing on reverse side. " <br /> Title: <br /> Signed K Date: <br /> Ff���D ARTMENT USE ONLY _ % J o ' Stk 466-67 <br /> Application Accepted by /"� [�'.wt�-�(lam/ - Area <br /> Lodi 369-3 21 <br /> Additional Comments: �s <br /> Pit or Grout Inspection by Date .Z j Manteca 823 1 104 <br /> Final Inspection by ❑�-� <br /> Date Tracy 835-6385 <br /> " y <br /> Applicant - Return all copies to: Environmental Health Permit/Services 160 E, H zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> EEE BASE AMOUNT DUE AMOJNT REMITTED RECETVED BY DATE PERMIITIINO. <br /> 10/82 500 <br /> EH 13-24 EV. 10/82 `k,: (� <br /> } <br /> 14-26 <br /> 1 <br />