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40 APPLICATION FOR PERMd- <br /> SAN JOAQLiN LOCAL HEALTH Di.SIR,[CT / <br /> 1501 E. HAZELTW A'JE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6751 <br /> • DATE ISSUED <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED .- om­ i��l <br /> (Complete in Triplicate) /�' 0 T <br /> Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and/or install the work hePein <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 f the San Joaquin Local Health D' <br /> Job Address j C{, �' D a Sµbdivision Nam st " <br /> Owner's Named—�1 A►1� I�} Address , r/ Phone <br /> Contractor's Name c o-:.d� License.No. Phone ��" 4_ <br /> _ F <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ]❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LI <br /> DISTANCE T_0 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE^ TYpE 6WELL• . PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IJ Industrial ❑ Open,Bottom ' [� Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private r Y ❑Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public Other"., Delta *. <br /> ❑ ❑ ❑ Type of Casing <br /> ❑I irrigation Approz;- _ ❑-Eastern Specifications <br /> F-1 Cathodic Protection Depth ,;; <br /> Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> ❑Other '' � :+ Surface Seal Installed by <br /> -q Repair Work Done E] Type of Pump H.P. State Work Done <br /> Welyl Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> 'TYP1 OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Le Commercial Other' t <br /> 1 Number of bedrooms Lot size <br /> Number of lliving Itnats: _ 4 T- � / <br /> Character of�soil to a depth of 3 felt: ' Water table depth <br /> ` " F ° Capacity ('3� No. Compartments <br /> SEPTIC TANKI DCI Type/Mfg e ` . I G , <br /> PKG. TRERTMENT,P'T: Type/Mfg -r Capacity Method of Disposal <br /> SEWAGE,.SYS7.iM.,O d 'Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LjEACHING L 'NE No. & Length of lines r/+ r`�y} Total length/size <br /> i,JPro Property Line <br /> FILTER�BEU ���Y Di-stance to nearest: Well Foundation P Y <br /> SEEPRGE-PfTS ❑ 6epfh Size Number <br /> ''., Foundation 'Property Line <br /> SUMPS -�•-:i,�,�� Distance tq near <br /> est: Well <br /> DISPOSAL PONDS ❑I* y <br /> I hereby certify that I have prepa1'ed this application and that tike work will be done in accordance with San Joaquin county <br /> ordinances,-state laws, and rules and reg tions of the San Joaquin Local Health District. <br /> j Home owner or licensed agent's signature rtifies the following: �'J certify that in the performance of the work far which this <br /> S permit is issued, I shall not employ an erson in such manner as tb,,.become subject to workman os compensation laws of California." <br /> CoNtrattor's hiring or -c act' g 9 tore certifies the following" "I certify that in the performance of the work for which <br /> this permit is i I s 1 em y p r rs subject to workman's compeQsation laws of California." <br /> The applican ust a r spections. Complete drawing o``n� reverse side. <br /> Signed X <br /> Title: Date: <br /> F DEPARTMENT SE ONL J Stk 466-6781 <br /> Application Accepte ,by Area > ❑ <br /> I Lodi 369-3621 <br /> Additional Comments: ❑ <br /> Pit or Grout inspection <br /> Date I4anteca 823-7104 <br /> Final Inspection by 64 Date6= � ❑ Tracy 835-6385 <br /> Applicant -.Return all copies to:- En vi onmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Bax 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO 800 IVV P r _gs mss- 973 <br /> l K <br /> 10192 5DD <br /> EH 13-24 REV 10/82 C 3 007 <br /> 14-25 <br />