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APPLICATION FOR PERMIT <br /> SAN JOAQLiN LOCAL HEALTH DISTRICT <br /> 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. %a-N ZR <br /> Telephone (209) 466.-6781 <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 District, <br /> Job Address J 7 e M l Subdivision Name <br /> Owner's Naml Address Pho <br /> Contractor's Name License No. S — Phone e2 4,:gam! <br /> 1 <br /> 03 <br /> TYPE OF WELL/PUMP 14ORK: NEW WELL ❑ { WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER I4ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom ❑ Manteca Dia. of-Well Excavation <br /> U Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public F—[Other Ll Delta Type of Casing <br /> L_iIrrigation Approx. Eastern Specifications <br /> F—ICathodic Protection Depth <br /> Depth of Grout Seal <br /> LJ Geophysical Type of Grout <br /> Other Surface Seal Installed by -- <br /> Repair Work Dane El Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501} <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION -�J REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _f Commercial _ Other <br /> ' Number of living units: Number of drooms 3__..__.__ 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 >41:& Foundation _lb Property Line <br /> DESTRUCTION ❑ f <br /> LEACHING LINE No. & Length of lines X f Total length/size 0 <br /> FILTER BED _ [] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth � Size <br /> 3 ` Number 7� <br /> SUMPS U Distance to nearest: Well /,{ `Foundation Property Line <br /> DISPOSAL PONDS ED <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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hirin sub-contracting 'gnature certifies the following: "I certify that in the performance of the work for which <br /> this permit is sued I shall employ rsons ubject to workman's compensation laws of California." <br /> The applica must all for all re it d �bmptete drawing on reverse side. 2 <br /> Signed X Title: Date: <br /> OR PARTMENT USE ONLY <br /> Application Accepted by Area [WStk 466-6781 <br /> Additional Comments: F] Lodi 369-3621 <br /> 5-11 <br /> Pit or Grout Inspection by Date (/ 3 U Manteca 823-7104 <br /> Final Inspection by Date ld /� L Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r1NF0 <br /> BASE AMOUNTDUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br /> 4 <br />