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op <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - 1601 E. HAZLLTON AVE., STDCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUE q <br /> (Complete in Triplicate) 223`- 2Y©li 0/ <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 compliannce itnftW County Ordinance No. 549 for sewage or. No. 1862 for well/pump <br /> gd -Rules and Regulations of the Sane*Ai CCbbcal11H� i'�i Tct• <br /> "tom A ressTxF?5 /177�`91P$�^ Subdivision Name �� r <br /> Owner's Name S i ;�� j�,,,,�•.,, Address 0 �1.dY oZCr3� Phone 3_ <br /> Contractor's Name License No. Phone , <br /> 4 <br /> TYPE. OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION F-1 SYSTEM REPAIR OTHER U b <br /> D- IANCE TO .NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 0i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �I ) <br /> it <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4— ` <br /> Industrial U Open Bottom C1 Manteca Dia. of Well Excavation <br /> Domestic/Private ❑ Gravel Pack [] Tracy Dia. of Well Casing <br /> LL] Public FJ Other Del to f3fq{j�� <br /> Irrigation Approx. Eastern Type of Casing (C10L !� <br /> Depth Specifications '' <br /> Cathodic Protection [� <br /> Depth of Grout Seal <br /> 1-1 Geophysical �I <br /> Type of Grout <br /> ❑Other !' <br /> Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter r� -- Sealing Material (top 50') <br /> iv <br /> Depth Filler Material (Below 50') II <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION j (No septic tank or seepage pit permitted if public sewer is; <br /> available within 200 feet.) �p <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: i Water table depth > <br /> SEPTIC TANK FLType/Mfg Capacity No. Compartments �• <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal ! <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line , <br /> DESTRUCTION <br /> O <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED E] Distance to nearest: Well Foundation Property Line I <br /> SEEPAGE PITS ❑ Depth Sizel Number <br /> SUMPS a Distance to nearest: Well, Foundation Property Line <br /> r <br /> DISPOSAL PONDS �1 <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,Joaqufn Local Health District. <br /> Home owner or licensed agent's signature certifies.the i%flowing: "I certify that in the performance of the work for which this <br /> permit is' issued, I shall not employ any pem on 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 p2lsons subject to workman's compensation laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. !! <br /> Signed X All .�� �«,^• _ Title: Date: <br /> 0 DEPARTMENT USE ONLY <br /> Application Accepted by 1 n 4,0'— Area Stk 4b6-6781 j <br /> Additional Comments: -�f E] Lodi 369-3621 1 <br /> Pit or Grout Inspection by Date - Manteca 823-7104 <br /> t <br /> Final Inspection by Date L7 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental He Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 �. 10/82 500 �I <br /> 14-26 <br />