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A <br />APPLICATION FOR PERMIT <br />SAN JOAQUiN LOCAL HEALTH DISTRICT <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) <br />Application is herS9��jYY the San•Joaquir Local Health District for a permit to construct and/or install the work herein <br />described. This <br />is made in compliance with San Joaquin Courty Ordinance No. 549 for sewage or No. 1862 for well/pump <br />and the Rules anal in <br />of the San Joaquin Local Health District. <br />Job Address W 9 SJ R100V,n®Subdivision Name <br />Owner's Name _ STIEit?J� Address /4 a Phone <br />Contractor's Name —7T6 CAM -11 -le License No. QINQf R Phone <br />TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT F_� DESTRUCTION <br />PUMP INSTALLATION SYSTEM REPAIR 17 OTHER LJ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WEt2IJ 1¢, OTHER 14ELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />ElIndustrial U Open Bottom Manteca Dia. of Well Excavation <br />U Domestic/Private F -I Gravel Pack Tracy Dia. of Well Casing <br />0 Public L1Other J E] Delta Type of Casing <br />F, Irrigation Appro J-01',E� Eastern Specifications <br />❑Cathodic Protection Depth J� <br />ro� Depth of Grout Seal - <br />L Geophysioa•lj Type of Grout <br />U Other Surface Seal Installed by <br />Repair Work Done ❑ Type of Pump H.P. State Work Done <br />Well Destruction ❑ Well Diameter Sealing Material (top 50') _ <br />Depth Filler Material (Below 50') <br />TYPE OF SEPTIC WORK: NEW INSTALLATION a REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br />mom" available witliih.200 feet.) <br />Installation will serve: Residence -9 Commercial —Other <br />Number of living units: __L_ Number of bedrooms d Lot size <br />Character of soil to a depth of 3.feet: , Water table depth <br />SEPTIC TANK E] Type/Mfg Capacity No. Compartments <br />.PKG. TREATMENT PLT. FE 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 0 D DMIWU Total length/size <br />_,F,I.LT,ER_BED _,.,Q _ Di,stance to. nearest WelI j1dW Foundation ,�i O° Property Line -- <br />SEEPAGE PITS Depth Size <br />SUMPSI�a",c^ L{ Distance to nearest: Well _ <br />DTSPOSA"t'-PONDS"'-"-'"`El <br />I Number <br />Foundation Property Line <br />r <br />I hereby certify that I have prepared thisl.application and^that the work wilh`be,done':in accordance with San Joaquin county <br />ordinances, state laws, and rules and regulations of the Sart Joaquin Local Health•Di-strict. <br />Home owner or licensed agent's signature certifies the following`-111_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 bec6me 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 persubject to workman's compensation laws of California.". <br />The applica call fo�all r . fired iso pections. Complete drawing on reverse side. l� <br />Signed X <br />f Title: �� Date: <br />F DEPARTMENT USE ONLY <br />Application Accepted by Area [] Stk 466=6781 <br />4,L tr, [] Lodi 369=3621 <br />Additional Comments: r , `' <br />Pit or Grout Inspection by Date Manteca 623 71I <br />I <br />$ Date`. r -- --� Traicy 835-6385 <br />Final Inspection by J__..�..� F <br />Applicant - Return all copi to: Environmental Health Permit/Services 1601 E. Hazelton Ave. P.O. B6x 2009, iStk � SCA 95201 <br />,r,,_RECEI51,ED BY_ DAT' <br />INFO <br />EH 13-24 REV. 10/82 <br />14-26 <br />10/82 500 <br />