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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT g3+ 1) <br /> d 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781T <br /> DATE ISSUED to'?--8'3 <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 CA <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump Cly <br /> and the Rules and u ations of th�S@n Joaquin Local Health District. <br /> Job Address 11 S v'sion Nam <br /> Owner's Name Address � �' Phone <br /> T� <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Open Bottom Manteca Dia. of Well Excavation <br /> 0 Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing <br /> j7 Public ❑Other ❑Delta <br /> Type of Casing <br /> [ Irrigation Approx. ❑ Eastern Specifications <br /> Cathodic Protection Depth <br /> Geophysical Depth of Grout Seal <br /> ❑Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Worl "` a of ump H.P. State Work Done — <br /> r <br /> ion 11 D' eter Sealing Material (top 50') <br /> pth Filler Material (Below 50') <br /> O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [ (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 SYSTEMDistance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ to <br /> LEACHING LINE ❑ No. & Length of lines Total length/size �. <br /> FILTER BED F-1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS [) Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> Horne 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 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 ap nt st call for all r uir inspections. Complete�draaw�in�g�Jon,irre/vverse side. <br /> Sign Title: � l�C%!* Date: <br /> r f _ FOR(Df�PA ENT USE ONLY ❑ <br /> Application Accepted by �����._ -� Area Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by r` OJC Date Tracy 835-63$5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 I"� ��.� 10/82 500 <br /> 14-26 l <br />