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APPLICATION FOR PERMIT <br /> SAN JOAQL'IN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone,(209) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby madeto the San Joaquin Local Health District fora 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 oftheSan Joaquin Local Health District. <br /> Job Addresslip Subdivision Name <br /> Phone <br /> Address <br /> Owner's Name <br /> Phone <br /> Contractor's Name License No, <br /> TYPE OF WELL/PUMP WORK. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> .. .. -- ---.P,UMP,-INSTAL-L-ATION-�-❑•­-SYSTEM-REPAIR.. --�-�-�-�••^--�•�*OTHER,�,❑_...,..-,:_ W <br /> SEWER LINES DISPOSAL�FLO. PROP. LINE <br /> .,DISTANCE TO NEAREST: SEPTIC TANK _-OTHER WELL PITS/SUMPS <br /> ' FOUNDATION AGRICULTURE WELL _ �_ -� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> t CONS7RUCTION.SPEC IFICATIONS <br /> 4t Dia ,of Well Excavation <br /> {❑ Industrial ❑Open Bottom ❑MantecaI, f �} <br /> t ❑ Domestic/Private is �]Gravel Pack ❑Tracy Dia..a of Well Casing <br /> Public "^ []Other ❑Delta Type of Casing <br /> Irrigation t Approxi Eastern <br /> ❑ Specifications <br /> Depth t <br /> IF-] Cathodic Protection Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> ❑Other Surface.Seal Installed by <br /> State Work Done <br /> Repair Work Done G jype of Pump <br /> H.P. <br /> if Sealing Material (top 501) <br /> Well Destruction ❑ Well Diameter <br /> j. �. <br /> ' Depth Fil3er Materi`aly (Below 50") <br /> 0 <br /> ` ` No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION �' ( available within 200 feet.) <br /> I Installation will ser : Residence Commercial _ Other { iY/ <br /> Number of bedrooms Lot size � d <br /> Number of living units,:}_ r <br /> L— . Water table depth <br /> %,.;.. <br /> Character of soil to a depth of-3 feet: . <br /> A.t <br /> Capacity L No. compartments <br /> SEPTIC TANK Type/Mfg <br /> / i Capacity Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg property Line <br /> SEWAGE SYSTEM f❑ r Di stance to nearest: Foundation <br /> Well � i t <br /> f DESTRUCTION E '{ <br /> _ a Total length/size i <br /> LEACHING LINE No. J& Length of lines t <br /> U F r Foundation P7 Well Property tine �l <br /> FILTER ADDistance to nearest:,aft . r <br /> size <br /> SEEPAGE Rip �1 Depth �`� Property Line <br /> Distance fofnearest: Well Foundation $ a <br /> SUMPS ,�.. z � � T <br /> DISPOSAL PONDS ❑ jI '+ <br /> i lication and that the work will be done in accordance with San Joaquin county t <br /> I herebycerti`fy thil have prepared this app <br /> ordinances, state laws, andirul•es and regulations of the San Joaquin Local y that On they <br /> Home owner or ',lic-ensed:agent's`�s 'gnature certifies.ythe following: "1 certify thats�n the performance of thein work for which this <br /> permit is issued,,I'soha1,1'nnensatio <br /> a tractingnsignatureicertifiesnthe followner as to ing�meIscertcfytthatrinathecperformance ofwthe fwork�for nwhich <br /> Contractor's hiring - ersons subject to workman's compensation laws of California." <br /> this permit-is issued, I shall°-..empldy .p f <br /> 'I c� , �-_ E--% e LLJ <br /> The applicant must ca 1 for, l requi•red:,jn5pections. Complete drawing on reverse side. Date: <br /> Signed X Title: <br /> R DEPARTMENT USE ONLY ,e 466-6781 <br /> li. ;- .—. Area 40 __.. 5=k <br /> Application Accepted by VE] Lodi 369-3621 <br /> Additional Comments: ` }_ -4� !nteca 823-7104 <br /> `Z11 i ' Date <br /> pit,ror Grout Ibspegti_on�byM.✓ '� f"`- ZQL_f� ,.L Tracy 835-6385 <br /> A x Date <br /> I Final Inspection bye _ y JZ 0. Box 2009, Stk., CA 95201 <br /> is +" ` <br /> Applicants 'Return._all:copes to:; Environment ealth Permit/Services 16 1 E. Hazelton <br /> { M�r PERMIT N0. <br /> AMOUNT REMITTED RECEIVED BY DATE <br /> i <br /> FEE BASE AMOUNT DUE <br /> INFO `--_--- <br /> -10/82 600_ Y.. . <br /> c EH 13-24 REV. 10/82 <br /> 14-26 <br />