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?V�;~ f} W <br /> r Z � APPLICATION FOR, PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ►3 PERMIT N0. g3 d S g <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) DATE ISSUED rZ� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t <br /> (Complete in Triplicate) <br /> t permit to construct and/or install the work herein l <br /> t l <br /> Application is hereby made to the San Joaquin Local Health District for p { <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 octal Health District. <br /> s1r s3 �,�yT�y Lla Subdivision Name <br /> Job Address Phone <br /> Owner's Name Jn e n+°7'��Y/� f Solt Address <br /> i /✓ License No. <br /> � y �9 Phone <br /> Contractor's Name .6, N� >� sD <br /> TYPE OF WELL/PUMP WORK: NEW WELL �] WELL REPLACEMENT DESTRUCTION }� <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> T SEPTIC <br /> TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I. <br /> T NEAREST:DISTANCE 0 --- OTHER WELL PITS/SUMPS <br /> FOUNDATION 1AGRICULTURE WELL <br /> INTENDED USE TY7E OF WELL PROBLEM AREA CONSTRUCTIDIV LSP ELI F•1CATIONS <br /> FF F-1 Industrial U Open Bottom Q Manteca <br /> Dia. of Well Excavation <br /> t ^ Dia. of Well Casing ' <br /> U <br /> Domestic/Private*.�c+,,,C0 Gravel- Pack Q Tracy " <br />' <br /> Public 1[)Ote` El Delta Type of Casing <br /> Eastern <br /> L_iIrrigation Deprox. l +rte Specifications <br /> Cathodic :Protection Depth r + <br /> lo+. �w-t is Depth of Grout Seal <br /> L7 Geophysical ' Type of Grout <br /> U Otherl o� ---Surface Seal Installed by <br /> 67 � Sta Work Done <br /> ❑ — <br /> Repair Work Done Type of Pump s <br /> Well Destruction U Well Diameter Sealing Mater^ialr {ttsp-50'� <br /> r r a <br /> k Depth mill-er Mater a,l.(Bel.ow_50' - <br /> 3 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION U {No septic tank or seepage pit. <br /> available ewithinif u200cfeetsewer }s <br /> Installation will serve: Residence Commercial Other ' <br /> ' Lot size fi3N <br /> ' Number of living units: +�,� Number of bedrooms <br /> s Water table depth <br /> Character of soil to a depth of 3 feet: �/4N� Ao&M Op Na. Compartments 13 <br /> SEPTIC TANK ig] Type/Mfg PYA Cd5 Ga0/e' -Capacity 4ZY <br /> {Capacity Method of Disposal <br /> i PKG. TREATMENT PLT. ❑ Type/MfgLine <br /> i SEWAGE SYSTEM Distance to nearest: <br /> Well Fouhdation Property; <br /> DESTRUCTION Q _ <br /> 4 1 -• ,-- tf ., Total length/size 3 y� <br /> ,. LEACHING LINE No: &.Length of .lines 8✓` , <br /> O ' y' <br /> Propert Line �0 <br /> FILTER BED 1--1Distance to nearest: Well /00 ' Foundation <br /> {�� Depth Size !3,6 pld$Fi: Number <br /> SEEPAGE PITS 3� p �5 , '; CF Pro erty 'Line <br /> SUMPS L Distance to nearest: Well Foundation - P <br /> E <br /> DISPOSAL PONDS } T <br /> ,prepared this application and that the work will be done in accordance with San Joaquin county <br /> I hereby certify that -I have <br /> ordinances, state laws;'andr:iiestiand regulations of the San Joaquin Local Health;District. <br /> Home owner or licensed ageno'tsesignatureany certifison es the <br /> sucfollowing:manner as to become subjectthat ntohworrkman� compensate performance of fionwlaws fof California." <br /> permit is issued, <br /> 5 Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this Actor' 'is'i's'sued;. I shall empl'4 persons subject to workman's compensation laws of California." <br /> ' The applicant m t call for all required inspections. Complete drawing 'on reverse side. 1 Date: <br /> Title: <br /> 1 Signed X � s <br /> �J R ➢EPAR7ME USE ONLY Stk 466-6781 <br /> Application Accepted by�/1/ Area Lodi 369-3621 <br /> dditjon�. ,Comments: ' <br /> ,gyp YY ft' } Date _z�r� Manteca 823-7104 <br /> tt !� <br /> Fit-er-6rveS-Inspection by } Tracy 835-6365 <br /> f Final Inspection by u/ i7ate �"-27- �� <br /> ff : <br /> _� Replicant - Return all copies to: Environmental Health,,.permit/ raises 1601 E. �elton Rve. �P~0. Box 2009, St k., CA 95201 <br /> 1, <br /> / PERMIT NO. <br /> ` AMOUNT REMITT•EO RECEIVED BYE- DATE�p. <br /> FEE BASE AMOUNT DUE q l 458 ,, t c�.0\ <br /> �i INFO M 1�t�j8� 5/Zb� 3— s <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> j s <br /> .14-26 <br /> F _ , <br />