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APPLICATION FOR PERMIT <br /> SAN JOA.QUiNL LOCAL HEALTH u1STRICT -7 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. I�7 <br /> Telephone (209) 466-6781 <br /> DATE ISSUED =S3 <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 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 San Joaquin Local Health District. <br /> Job Address / ubdivision Name <br /> Owner's Name Address. sgcj�j 0_ Phone <br /> Contractor's Name , J^� ,.a�3 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 'r SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WILL ^qQ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> - - F1 Industrial N U Open Bottom Manteca Dia, of Well Excavation <br /> Domestic/Private 'Gravel Pack Tracy Dia. of Well Casing <br /> 0 Public F-1 Other Delta s <br /> Ljirrigation .210 f Approx. 0 Eastern Type of Casing <br /> Depth Specifications <br /> [ <br /> �Gathodic Protection Depth of Grout Seal s�J_ 6-1 Z4Z <br /> Geophysical <br /> Type of Grout <br /> Other <br /> Surface Seal Installed b., <br /> Repair Work Done [_J Type of Pump <br /> H P State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <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.) <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 Cj Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. Type/Mfg Capacity Method of DisposalQIR <br /> Cr <br /> SEWAGE SYSTEM Distance to nearest:- Well Foundation Property Line 1 <br />` DESTRUCTION C <br /> LEACHING LINE U No. & Length of lines Total length/size r' <br /> Ir FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS F—j Depth Size Number <br /> E SUMPS IJ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D (� <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 <br /> istrict. -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 workmari� 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 ca 1 a ed F4spec.tions. Complete drawing on reverse side. <br /> Signed X �. Title: , i_ Date: " <br /> F R DEPARTMENT USE ONLY <br /> Applicati n Accepted by �. Area 4 Stk 466-6781 <br /> Additional Comments: <br /> s, Lodi 369-3621 <br /> Pit or Grout Inspection by Date y ❑ Manteca 823-1104 <br /> Final Inspection by Date �L7 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r1?N <br /> BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> IE 0 CT7 r <br /> b J <br /> EH 13-24 REV. 10/82 y� ```` 10/82 500 <br /> 14-26 f fN *� e-�LeC �� Z� <br /> l <br />