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1 <br /> �UF�►l�la�'-O -- <br /> APPLICATION FOR PERMIT . <br /> SAN .OAQUIN LOCAL HEALTH DISTRICT Q <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) `t <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 aQ_nd�Rggulations of t e San Joaq in Local ealthDistr' CA <br /> Job Address O'7C/7 Suhdi_v CA <br /> Owner's Name Address 00' e <br /> el <br /> Contractor's Name cense No. <br /> ' Phe <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <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 U Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Domestic/Private E] Gravel Pack Tracy Dia. of Well Casing <br /> Public [—I Other Delta Type of Casing <br /> Irrigation Approx. Eastern Specifications 60 <br /> Cathodic Protection Depth _J <br /> Depth of Grout Seal <br /> Geophysical Type of Grout <br /> 0 Other Surface Seal Installed by <br /> Repair Work Done Type of Pum ph.P. .3 State Work Dane <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 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM c Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation.. - Property Line <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 /> 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 applic must 11 for all required i pections. Complete dr/�y),ing on verse ide. r <br /> Signed X <br /> Title: + ��/�� Date: <br /> FP DE TM ENT E ONLY Stk 466-6781 <br /> Application Accepted Area d <br /> Lodi 369-3621 <br /> Additional Comments: <br /> Pit or Grout Inspection Date LJ "Manteca 823-7104 <br /> Final Inspection by � <br /> Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies 0. En4rm,,,,taealthPermit/Services 1b01 E. zelt0n Ave., P.O. Box 2009, Stk., CA 95201 <br /> FFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> FD Lt ND �'0 91? IO/B2 500 <br /> EH 13-24 REV. 10/82 n ` 1� <br /> 14-26 IJ <br />