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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � <br /> * Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED —C* <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 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 Sano Paquin Local Health District. <br /> Job Address .27 i/2¢ V C ', Subdivision Name t //57 <br /> Owner's Name 1_ f ` Address 16. �I4rt?�Cly[��.. 7/^Q�{/, Phone _ga5- <br /> Contractor's Name F License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK i /op` SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ( AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 1 <br /> INTENDED USE TYPE ;OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom ❑Manteca Dia. of Well Excavation A/ _ <br /> Domestic/Private [vravel Pack racy Dia, of Well Casing `/P <br /> Public [—I Otheir Delta <br /> I Type of Casing <br /> FF Irrigation Approx. Eastern F <br /> Depth Specifications <br /> ❑ Cathodic Protection P <br /> Depth of Grout Seal � <br /> Geophysical Type of Grout /Lt <br /> - <br /> u Other <br /> Surface Seal Installed by <br /> Repair Work Done E] Type of Pump H.P. State ,Work Done _ <br /> Well Destruction U Well Diameter- Sealing Material (top 501) - <br /> Depth Filler Material (Below 50') p� 1) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION LI (No septic tank or seepage pit permitted if public sewer is f7 <br /> available within 200 feet.) pLj <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 Type/Mfg, Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg' Capacity Method of Disposal <br /> Distance'.to nearest: Well Foundation Property Line <br /> ( <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Distance!to nearest: Well Foundation Property Line <br /> SEEPAGE PITS n Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <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 /> The applicant wst call for 11 r Mired inspections. Complete drawing on re rse side. <br /> Signed X Title: Date: 3� <br /> D A M NT USE O Y ' <br /> Application Accepted by Area U -7 [] Stk 466-6781 Z/j y <br /> Additional Comments: EJ Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by f Date Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., TO. 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 �} Q� }l S� 10/82 500 <br /> 14_26 vv� <br />