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no, <br /> APPLICATION FOR PERMIT <br /> ����� SAN JOA(}UiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> SAN JOAQUIN LOCA Telephone (209) 466-6781 <br /> LOCAL DATE IS$UE0 <br /> HEALTH DISTRICT 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 caquin Local Health District. <br /> Job Address 41 as/R Subdivision Name <br /> Owner's Name Address / Q d x D 0)�k Phone <br /> Contractor's NaweMVeg;-JAW,r WATOR 90 a No. 4(. 7G5!46_ Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> DISTANCE TO NEAREST: SEPTICMTANKSTRLLA7ION <fSEeW R LINE E/ eh <br /> DISPOSALRFLD.� PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial �— Open_8ottom _ _ ❑ Manteca v _ Dia._ of Well Excavation <br /> Domestic/Private Gravel Pack a Tracy Dia. of Well Casing <br /> ❑ Public F—i Other Delta Type of Casing <br /> Lj Irrigation Approx. [] Eastern Specifications <br /> ❑ Cdic Protection Depth !•� <br /> athoroecDepth of Grout seal <br /> Geophysical Type of Grout <br /> ❑Other Surface Seal Insttaa led by <br /> Repair Work Done ❑ Type of Pump v 13 H.P. State Work Done &.(/.& &I'sT/ G L!t1p INl� <br /> Well Destruction [J Well Diameter Sealing Material (top 50') E A �a a r <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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM 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 [j Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line - <br /> DISPOSAL PONDS CI <br /> 1 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 workmanK compensation laws of California." <br /> Contractor's hi in or sub-cont cting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit i issued �arequyir <br /> ns subject to workman's compensation laws af.California," <br /> The applica ust caspections. Completepdr wing on reverse side' <br /> Signed Title: 7-R14 02 T Date: <br /> D RRTMENT USE Y <br /> Application Accepted by Are "� I Stk 466-6781 <br /> Additional Comments: '��C. [odi 369-3621 <br /> Pit or Grout InspectiX, Ln,74,'n-entai <br /> Date LJ Manteca 823-7104 <br /> Final Inspection by Date ,,�� Tracy 835-6385 <br /> Applicant - Return all copie Health Permit/Services 160 E. azeltorY , .1 P.O. Box 2009, St k., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/32 10/82 500 <br /> 14-26 <br /> i- <br />