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APPLICATION FOR PERMIT <br /> _SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0._B a �J(4 ly� <br /> Telephone (209) 466-6781 <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 j <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..pn4 R ulati ns of the San Jo q.in Local Health.District. <br /> Job Address - — Subdivision Name <br /> Owner's Name Address �`� d � Phone <br /> Contractor's Name ) E_i=_ V�j'�LL _License No. j-�1� _ _ Phone fl ;its <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION S� <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER i <br /> _DISTANCE TO-NEAREST-SEPT IC-TANK--­7-SEWER-CI NES" DISPOSAL-FLS. K0P`CINE-- I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial U Open Bottom ❑Manteca Dia, of Well Excavation <br /> Domestic/Private ❑ Gravel Pack [-i Tracy Dia. of Well Casing i <br /> blic f' Other Delta <br /> . _.r{�Pu --- �r 1- -- ®-... Type-of`Casing <br /> {J Irrigation Approx. Eastern <br /> Depth � Specifications <br /> E]Cathodic Protection P <br /> Depth of Grout Seal <br /> [-.Geophysical Type of GV- ut <br /> F-1 Other j Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction Lf Well Diameter Sealing Material (top 50') 1 <br /> Depth iT Fl11er Material (Below 501) 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-U—REPA•IR/ADDITION % (No septic tank or seepage pit permitted if public sewer is r <br /> available within 200 feet.) op <br /> Installation will Serve: Residence )(- Commercia} Other i �n <br /> Number of living units: T� Number of bedrooms` Lot size -Xcl <br /> Character of soil to a depth of 3 feet: �I _ ) Water table depth <br /> SEPTIC TANK ❑�^ Type/Mfg —Capacity- - No. Compartments <br /> PKG. TREATMENT PLT. E], Type/Mfg Capacity Method of Disposal <br /> 3 j i Distance to nearest: Well d ounlation Property Line <br /> LEACHING LINE _ 3 1 No..&..Length,of lines Total length/size 0 E <br /> i FILTER BED Distance to nearest; Well Foundation Property Line <br /> _ _SEEPAGE PITS hl 'w ( a} Depth c��. { Size Number <br /> 7 <br /> SUMPS ,)Di stance'to'nearest: Well Foundation Property Line <br /> ` , <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 workman§ compensation laws of California." <br /> Contractors 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 /> ica t must cal• for all r ired i pections. Complete dr ing ou--remerse <br /> ± S - - Title: .fps (Yate: lo <br /> _ <br /> ir FDEPARTMENT USE ONLY <br /> Application Accepted by eta, _�"�-���.!{ 4.- Area C L �_.Stk 466-6781 <br /> Additional Comments- /!/ [] Lodi 369-3621 <br /> 1 Pit or Grout Insp ction b _ _ ate Manteca-.823-7104 <br /> Final Inspection by �^ Date /d % Tracy 835-6385 <br /> i <br /> Applicant - Return all copies to: Environmental Health Permit/Services 16 TE. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> { ice FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO rr <br /> EH 13-24 REV. 10/82 - - + ? 10/82 500 <br /> 14-26 <br />