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dam- <br /> DAPPLICATION FOR PERMIT <br /> SAN JOAQLi` LOCAL.HEALT <br /> k <br /> DiSiRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 7%14AOS I <br /> Telephone (209) 466-6781 ' i <br /> DATE_ISSUED <br /> IC-J24-:-774 �-� PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> AN JOAQUIN LOCAL (Complete in Triplicate) �. <br /> HEALTH DISTRICT <br /> Application is hereby made to i'he 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-Regulationsl.olf the Sa ,rJJ,oac,uin Local Health <br /> •'District. <br /> Jab Address id,id, <Ji'� i�iVo TJame <br /> Owner's Name ►- C'.D Ass Q ite Phon <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP,INSTALLATID SYSTEM REPAIR �I OTHER LJ <br /> DISTANCE .TD:NEAREST:SEPTtCTANK` W.. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> £ FOUNCAT•ION ��"y AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �F Industrial- Ly-open-Bottom f - Manteca ' Dia.}of Well' Excavation <br /> LJ Domestic/Private0 Gravel Pack, r-1 Tracy Dia. of Well Casing <br /> 1 <br /> Public Other Delta ;Type of Casing <br /> J Irrigation - QQ�Approx: Eastern` Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> L]Geophysical Type of Grout ; <br /> U Other Surface Seal Installed by <br /> Repair Work Done Ej Type of Pump Slt - H.P. State Work Done !i <br /> Well Destruction U Well Diameter 1Q." Sealing Material (top 50') <br /> Depth Filler Material (Below 50') { <br /> `'- TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is i <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 ❑ Type/Mfg Capacity f No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Q Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS pt 6 Size r Number <br /> Dincerto'nearest: Well Foundation` "Property Line <br /> SUMPS sta <br /> DISPOSAL PONDS SCI <br /> F <br /> I hereby certify that LI�have prepared this application and that the work will be done in accordance with San Joaquin county <br /> t ordinances, state laws, and rales and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the fallowing: "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 wmus a allTrequired inspections. Complete drawing on reJerce side. <br /> Title: Q Date: <br /> Signed X / <br /> FO DEPARTMENT 5 ONLI� Stk 466-6781 /r�r C A 7c <br /> Applica on Accepted by�/1� Area k <br /> [] Lodi 369-3621 <br /> Additional Comments: <br /> ' Date Manteca 823-7104 <br /> Pit or Grout Inspection by <br /> Final Inspection by <br /> Date Tracy 835-6385 <br /> Applicant,- Return all copies to: �ironmertal ��e.lthPermit/Services 1601 EE Ha*hon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT CUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO '5-54 -to W <br /> 71 �!,7y10/ 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />