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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �3� 72(.0 fti 4 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 7vZ?P <br /> Telephone (209) 466-6781 1 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM 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 it compliarce with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the 5 n Joaqu' eaI H lth Distr' t. <br /> Job Address441 <br /> �7 V uhn Nam ` <br /> Owner's Name Addr s Irk <br /> one <br /> Contractor's Name License No. Phone r <br /> TYPE OF WELL/PUMP WORK: NEW WELL - WELL REPLACEMENT �_. , DESTRUCTIONS <br /> PUMP INSTALLATION SYSTEM REPAIR LUTHER Li w <br /> DISTANCE TO NEAREST: SEPTIC TANK SE4 CZWER LINES _ ?��_ DISPOSAL FLD. g M— PROP. LINE p0 <br /> 1 <br /> FOUNDATION H4 AGRICULTURE WELL OTHER WELL _ N/a- PITS/SUMPS 4 l <br /> INTENDED USE TY^E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I�J Industrial Open Bottom E] Manteca Dia, of Well Excavation ✓-y <br /> U Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br /> PublicEj Other Delta Type of Casing ® 4 <br /> irrigation Approx. Eastern Specifications <br /> Iathodic Protection Depth <br /> Geophysical Depth of Grout Seal , <br /> U Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done G Type of Pump H.P, �. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> .w <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION R£PAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is f <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK l Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM ci Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS �j Depth Size Number t <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <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." c <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 /> The applic must c for all required inspections. Complete dVywing o r verse side. <br /> Signed x. Title: Date: <br /> P ENT ONLY <br /> Application Accept by Area 9 Stk 466-67 <br /> Additional Comme ts: Lodi 369-3621 <br /> Pit or Grout Inspec ion by Date Manteca 823-7104 k <br /> -Final Inspection by f Date L Tracy 835-6385 f <br /> Applicant - Return all copies t Enviro mental Health Permit/Services 1601(E. Kazelton Ave., P.O. Box 2009, Stk•, CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO fte- 917 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />