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t <br /> c <br /> P <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ' <br /> Telephone (209) 466-6781RM1f GD. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 .Ru'le k and Reg lations of the San Joaquin Local h District. <br /> Job Addres' �� <br /> D Subdivision Name <br /> Owner's Name A R A4,,tSs_yAddress <br /> ,Phone <br /> Contractor's NameLicense No. <br /> « Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT[ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL t ''j OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA t-�CONSTRUCTIGN SPECIFICATIONS <br /> 17,Industrial ❑ 'Open Bottom � ❑ Manteca {'Dao. of Well Excavation <br /> U ! i <br /> ❑Gravel Pack,� TracyDia, of Well Casing <br /> 17 Public ❑Other s ( El Delta t I <br /> Li <br /> _I Irrigation 1! *j!Type of Casing <br /> Approx. [J Eastern <br /> C6th6dic Protection-..1 Depth Specifications <br /> E Geophysical "t.. Depth of Grout Seal ; <br /> r P 1 <br /> U,Other Type of Grout <br /> I I %� ; Surface Seal Installed by <br /> Repair Work Done E] Type of Pump H.P. r.` 1, -56te Work Done S _ <br /> Well Destruction Well Diameter ing Material (top 501) N <br /> Depth Filler ftterial (Below 501) <br /> TYPE'OF.SEPTIC WQRK`—NEW IHSTIILLATrON' 't2-E-PA�ii2ADOTI$M <br /> { I �U {No`�se�tic tank o'r seepage seepage-pi <br /> permitted'"if�pu6lc'-sewer4{is'`' <br /> Installation will serve: Residence, Commercial Other , oval i ble within 200 feet.) - <br /> Number of living units: Number of bedrooms <br /> — � Lot size fC <br /> Character of soil to a depth of 3 feet: /�" Water table depth 7 <br /> SEPTIC TANK Type/Mfg <br /> + '' Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfgy Capacity r, Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well ' 3 <br /> j DESTRUCTION Cllk.': /Foundation i r Property Line <br /> LEACHING LINE '�'� No. &'Length of lines <'r + � 7— <br /> /size <br /> : q Total length I <br /> FILTER BED Distance to nearest: Well Foundation rL!FR7'Property Line <br /> SEEPAGE PITS Depth _ Sizes i_ Nber <br /> SUMPS Distance to nearest: Well /TTI dation Property 'Line <br /> DISPOSAL PONDS EJ � I <br /> I .hereby certify that I have prepared this application and Ahat the work will' be done in accordance with.,San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San,Joaquin Lqcal Hdalth District. NZ, Nom. <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, ; shall notFempioy any person in such manner as to become subject to workman compensation"lawslof California. f <br /> Contractor's hiring or sub-coptracting 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 /> 1 I <br /> The applicant must call for fl.fired{' ections.--- <br /> Complete drawing on'reuerse side. - <br /> Signed X c / Title: . �f+ <br /> Date i' y <br /> Application Accepted by] <br /> AR T USE ONLYArea 02 ❑ Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspectian!by Date Manteca 823-7104 <br /> Final Inspection by ! r paw/%fy Tracy 835-6385 <br /> Applicant - Return all copies to: EnvironmeHealth Permit/Services 1601--E. Hazelton Ave., P.O. Box 2009, Stkl. CA 95201 } <br /> FEE BASE e'AMOUNt DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT No <br /> ( INFO ` <br /> .�EH 13-24 REV. 10/82 10/82500 <br /> 14-26 f <br />