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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. --� <br /> Telephore (209) 466-6181 t <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 , <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 Distric <br /> Job"Addressst�ri <br /> Owner's Name ddress // PhoneQ95 <br /> 5 ,-z1IQ,? [ <br /> Contractor's Name License No. PhoneAwlk--S&A2 (T! <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL !PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial U Open Bottom ❑Manteca Dia" of Well Excavation <br /> LI Domestic/Private Gravel,,Pack 0 Tracy,,,_ Dia: of Well Casing t <br /> Public FJ Other - ❑ Delta Type of Casing <br /> V Irrigation 'App z [] Eastern Specifications <br /> ❑ <br /> Cathodic Protection y <br /> -Depth- <br /> Cathodic <br /> iDepth of Grout Seal Q ,� <br /> Geophysical , = Type of Grout <br /> U Other Surface Seal Installed by ► <br /> { ~x <br /> "�^-- State Work_ Dane I l( <br /> Repair,Work Done E] Type of Pump H.P. � . <br /> Well Destruction U Well Diameter Sealing Material (top 501) :x. <br /> t pepth i. Filler Material (Below 50') <br /> t i <br /> TYPE{OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permittedif public sewer is <br /> available within 200 feet.) ! <br /> Installation will serve: Residence-,,k- Commercial _ Other <br /> 4: <br /> Number of living units} Numbersof bedrooms ?� Lot size & f. <br /> Character of soil to a'depth of 3'feet Water table depth /� <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> 7o Capacity G <br /> PKG. TREATMENT PLT. � Type/Mfg � P Y Method of Disposal <br /> SEWAGE SYSTEMDistance to nearest: Well `=Foundation Property Line C� <br /> DESTRUCTION Q ! $ -,•' n v <br /> LEACHING LINE . No. & Length of'ltnes Total length/size �{J <br /> FILTER BED £ Distance to nearest:$ Wellt %[�!, Foundation � Property Line �� } <br /> SEEPAGE PITS * Depth; Size may' Number. <br /> SUMPS Distance to nearest: WellFoun O Property Line ft7 kr^ <br /> 3 t <br /> DISPOSAL PONDS 7J ; 1. <br /> I hereby certify that I have prepared this applica.tion`and'that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules,rand 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 /> Contractorsignature Certifies the"fo3'1'owingi'"I certify that in the performance of the work for which <br /> 's hiring or sub-contracting <br /> this permit i issued, I shall emplo pers subject to workman's compensation laws of California." <br /> The appli t call f all r red ns ctio Comple e n reverse side. f <br /> Signed X Title: •..L�� Date: <br /> TM ENT ONLY ❑ <br /> Application Accepted b Are Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> { Pit or Grout inspection by` Date - Manteca $23-7104 <br /> Final Inspection by Date i ¢__-''3 ❑ Tracy 835-6385 <br /> Applicant _ Return all coRpi s to:, Environmental Hea h Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk:, CA 95201 <br /> EEE -77 <br /> BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> _ <br /> m,r4.� t ;l A C' a btir ;;"Sr�w 10/82 500 <br /> EH 13-24�REV. 10/82 - _ <br /> 14-26 <br />