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�t M <br /> II <br /> h APPLICATION FOR PERMIT <br /> II SAN JOAQUIN LOCAL HEALTH DISTRICT R <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED GATE ISSUED b <br /> I. <br /> Y (Complete in Triplicate) f <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_471tv dll, uk �� � Subdivision Name <br /> Owner's Name AddressPhone1 <br /> Contractor's NamePhone <br /> License No. 6Q06o� W <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 FLD. PROP, LINE ~ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ,i. <br /> i.TYPE OF WELL PROBLEM AREA CDNSTRUCTION SPECIFICATIONS � <br /> J Industrial U Open Bottom D Manteca Dia. of Well Excavation 1t <br /> Domestic/Private 0 Gravel Pack Tracy Dia. of Well Casing ` <br /> I] Public E_j Other Delta <br /> Type of Casing <br /> Irrigation !I'' Approx. Eastern <br /> Depth Specifications <br /> EJ Cathodic Protection Depth of Grout Seal <br /> Geophysical <br /> U �E Type of Grout <br /> Other <br /> Surface Seal Installed by <br /> Repair Work Done EJ Type oflPump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION A11 (No septic tank or seepage pit permitted if public sewer is <br /> ;i- 1available within 200 feet.) /1 <br /> Installation will serve:` Residence <br /> Commercial Other <br /> Number of living units: Number of bedrooms 6 Lot size 7— <br /> Character of soil to a depth of 3 feet:. Q �! _ Water table depth (�Q <br /> SEPTIC TANK jj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal i <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line p <br /> DESTRUCTION Q :� 4 <br /> LEACHING LINE No: & Length of lines 1 -20? Bp Total length/size f Do!eS 2 <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( j Depth �t -_ Size H S ' Number 3 i <br /> SUMPS L-1 D.istance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 0` <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 /> 1V <br /> The applicant must cal for all r aired p ctions. Complete drawing o revers side. <br /> Signed X Title: y�.yr Date: "Z <br /> I) F ARTME SE ONLY <br /> Application Accepted y Area & (] Stk 466-5781 i <br /> Additional Comments: 'I s� Lodi 369-3621 i <br /> Pit or Grout Inspection by Date to—FZ�3 Manteca 823-7104 <br /> Final Inspection by Date > �'3 L7 Tracy 835-6385 <br /> Applicant - Return all co es' Environmental health—Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> a <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO It <br /> EH 13-24 REV. 10/82 I 10/82 500 <br /> 14-26 ik ` <br />