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w APPLICATION FOR PERMIT <br /> SAN JOAQLiN LOCAL HEALTH DISTRICT <br /> 1501 E. HA�i'LTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephc6e; (209),466;6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) ' <br /> Application is hereby made to the San'doaquin 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 oLeS� aquin Local . alth District. <br /> j Jab Address ' Subdivision Name <br /> 'Owner's Na Address <br /> on; <br /> Contractor's Nam License No. Rhone a <br /> �. <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> 0 PUMP <br /> } DRSSTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES '' <br /> - DISPOSAL FLD. I PROP. LINE <br /> . FOUNDATION - AGRICULTURE WELL OTHER IJELL I PITS/SUMPS a <br /> INTEN-DED USE r I <br /> r _ TYPE WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial~, U Open;Bottom Manteca "'� <br /> ❑ ,._s�,Dia:,.of Well Excavation <br /> U Domestic/Priva62, ❑ Gravrl Pack Tracy Dia"of�WelilVCasing } <br /> Public Other <br /> ❑_ 3 []Delta <br /> Irrigation -j � Type of Casing l <br /> � pprox, ❑Eastern -- <br /> i [ Cathodic Protection i depth Specifications i <br /> Geophysical a' �� � - —�°°flepth-of-Grout Sea• <br /> ❑Other Ij #` Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump _ �. H.P. State Work Done <br /> Well Destruction ❑ well Diameter tiSeali g aerial {tap 50') <br /> Depth Fi'1=1e, Material {Below 50' <br /> TYPE OF SEPTIC WORK: NEW lNSTRLLATIOM; REPA R A IT,.0O , ❑ (No septic tank or seepage pit permitted if public sewer is <br /> e f available within 2DD feet.) <br /> Installation will serve: Residnt/e Commercial <br /> �e" 4 <br /> Number of living units: 1 Number of bedroo Lotisize $ <br /> Character of sail to a depth of 3 f t: "t Water table depth <br /> SEPTIC TANK Type/Mfg .app1, Capacity 1AC.0 p No. Compartments .o <br /> PKG. TREATMENT PLT. ❑ Type/MfgCapacityy1'- Method of Disposal / C <br /> SEWAGE SYSTEM x /�/� <br /> Distance to neai^est: ,Well J tib Fourdation Property Line r'` <br /> DESTRUCTION ❑ P y ,�/ <br /> s, . �. <br /> LEACHING LINE No. & Length of lines Total}1'ength/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation �F Property Line —_ <br /> SEEPAGE PITS Depth Size Number { ? <br /> �.. <br /> SUMPS �� Distance to nearest: Well / �.gqpundation;l ,Property Line k <br /> DISPOSAL PONDS <br />€ _ ryas <br /> 1 hereby certify that I have prepared this application and that the dark will ',be done in accordance with San Joaquin .county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Hearth District, <br /> Home owner or licensed ent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I s 7 not employ any person in such manner as to become subject to workman compensation laws of California." <br /> Contractor's hiring sub-contracting s' a re certifies the following: "I certify that in fhe performance of the work for which <br /> this permit is i I shall employ r s sub' ct to workman's compensation lawstof Califo Ahia." + <br /> The appl call r all ins Compl reverse side. _ _ <br /> Ti le; Date-/ <br /> OR MEN SE ON <br /> Application Accepted , Area N - Stk 456-6'81 <br /> Additional Comments ❑ Lodi�. 369-3621 <br /> Pit Grout Inspection by c~ Date Manteca 823-7104 <br /> final Inspection by Date L� -+,1-� Si Tracy 835-6385 <br /> Applicant - Return all Copies to- Environmental Health Permit/Services 1601 E. Hazelt n Ave.,jP,0�ox 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 6ATE PERMIT N0. <br /> INFO <br /> EH 113-24 4L26 REV. 10/82 4 <br /> 10/82 500 F <br />_ i <br />