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i ! APPLICATION FOR PERMIT (/ <br /> I " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 13-3'-� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED <br /> I (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 Regulati m of the San Joaquin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name Address P Phone _ - <br /> Contractor's License No. .ay6 phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL (� WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial 0 en Bottom <br /> . .Lj p ❑Manteca Dia, of Well Excavation <br /> L7 DolI mastic/Private L'Q Gravel Pack Tracy <br /> y Dia. of Well Casing <br /> Other <br /> II �Delta <br /> L] I igation 7 Approx. Eastern Type of Casing <br /> Cathodic Protection Depth "Specifications <br /> Gelophysical Depth of Grout Seal <br /> Otlher Type of Grout <br /> Surface Seal.Installed by <br /> Repai r Work Done ❑ Type 0i, Pump H.P. State Work Done <br /> Well destruction L0 Well Diameter Sealing Material (top 501) <br /> Depth . Filler Material jBelow_50 «= <br /> FF <br /> TYPE IF SEPTIC WORK: NEW INSTALLATION REPAI DO TION — (Wo Septic tank or see <br /> page pit permitted if public sewer is � <br /> Ins allation will serve: .Residence Commercial _ Other -� available within 200 feet.) <br /> a <br /> Num er of living units: s Number of bedrooms Lot size /-4e4icy O <br /> Character ofsoil'to a depth of 3 fye�,t�: . � Water table depth DO r <br /> SEPTIC TANK LK Type/Mf 1 t� <br /> 9 Q/ n Capacity 1-0in;) No. compartments <br /> PKC. 4REATMENT PLT. Type/Mfg Capacity ,Method of Disposal - <br /> Diitance to nearest: <br /> Well a� /e-Foundation ® Property Line <br /> e <br /> LEACHING LINE No! a Length of lines O Total length/size D <br /> FILTER BED ��. Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Death d Size _ " _ <br /> II` ----T_ >�� Number <br /> SUMPS 4 ❑ Distance to nearest: Well jF7FoundationProperty Line <br /> DISPOSAL PONDS <br /> s <br /> l3iri F �! <br /> I her certify that I have prepared this application and that the work will be done-in accordance with San Joaquin county <br /> ordinahces, state laws, and-mules and regul <br /> Home oGner oations of the San Joaquin Local Health,District. <br /> r licensed,agent-m signature certifies the following: "I, certify that'In the perfufdmnce of the work for which this <br /> permitlis issued, I shall not- mploy any person in such manner as to become subjec-t to'worknen4 compensation laws of California." <br /> Zontracting <br /> this <br /> Contractor's hiring or sum- signature certifies the following: "I ceFtify that in the performance of the work for which <br /> plermit is issued, I shall. employ persons subject,to-workman-s-compensation laws of-California." <br /> The applicant . st call for all r Tred inspe tions. Complete dra g on reverse side. <br /> Signed X ,Title: Date: <br /> DEP I IT U5E ONLY �/l <br /> Application Accepted Dyk Area �'i'^�Z�o ,J Stk 466-6781 <br /> Additional Comments: ~ • P -�7 -G— Lodi 369-3621 <br /> Pit or Grout Inspection by pate T � Pzelton <br /> Manteca 823-7104 <br /> Final Inspection by �?�, '_ pate ) Tracy 835-6385 <br /> Applicant - Return all coplesito: Environment&) Health-Permit/Services-1S E. Ave., P.C. Box 2009, Stk., CA 95201 l <br /> r. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT No. <br /> INFO <br /> S 5 a �3 83-3Lf ' <br /> EH 13 24 REV. 10/82 <br />