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APPLICATION FCR PERMIT <br /> I <br /> j <br /> SAN JOAQI ird LOCALE ,LTA, CiSIRICT 1 tir� <br /> j 1601 E. hAZELTON AVE.,ySTOCKTON, CA PERMIT N0. �/ <br /> j Telephone (209) 465-6781 <br /> DA ISS�UE�D�3-19�iY,, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> : (Complete in Triplicate) — o P I <br /> Application is hereby made to the San Joaquin Local'Health District for permit to construct and/oh 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 /> Jab AddressSC,A57%, Subdivision Name <br /> Owner's Name �/a - 7r_— Address` Phone <br /> Contractor's Name License No. '! Phone <br /> TYPE OF WELL/PUMP WORK: NEWWELL WELL REPLACEMENT F-1DESTRUCTION L] 'L <br /> PUMP INSTALLATION SYSTEM REPAIR �1 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOU17 <br /> NDATIAGRICULTURE WELL OTHER WELL""�"�`" PITS/SUMPS <br /> INTENDED USE TYPE)OF WELL PROBLEM-AREA � �� CONSTRUCTION SPECIFICATIONS <br /> I_J industr`ial j] Open Bottom Manteca `�" Dia'. of Well Excavation <br /> f0.U Domestic/ rivate (]Gravel Pack Tracy Dia. of Well Casing <br /> Public �� ' Othe`r Delta--w--- <br /> ��. �-' Type of 'Casing <br /> Li Irrigation.` -:, I 1I'Approx. j]Eastern Specifications <br /> 71 Cathodic Protection <br /> y % 4 I:Depth Depth of Grout Seal <br /> 1-1 Geophysical ' ' I Type of Grout <br /> Other ,. Surface Seal Installed by <br /> "� r�* <br /> Repair Work---Done ❑ Type of Pump State Work Done ti H.P. <br /> Well Destrdc-tion j]`�Well.Diameter Sealing Material (tap 50') - -� <br /> `�. <br /> L �.ailler Material (Below 50') <br /> "Depthvti <br /> TYPE Of SEPTIC.WORK} NEW iNSJALLATION L REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> �? <br /> availablywithin 200 feet.) <br /> lnstai�lati` an willResi.d`ence �� Commercial Other <br /> Number of living units: �!` Numbbr,of bedrooms Lot size <br /> ,.� Water table depth 47 <br /> Character of soil to a depth o,f 3 feet: _ , <br /> SEPTIC TANK Type/M ;;;- <br /> `t. "'Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity -� Method`of Disposal �1 <br /> SEWAGE SYSTEM. Distance to •nearest: WellF <br /> _ oundation` PropertywLi.ne r„ <br /> DESTRUCTION <br /> LEACHING LINE f No. & Length of lines -- ---T-^-Total length/s•ize <br /> FILTER BED Distance to nearest: Well Foundation �p 4�.Property Line <br /> { } <br /> SEEPAGE PITS Depthl" NumberM Size <br /> SUS Distance to nearest: Well Foundation ' Property-:Line <br /> MPS� <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the wor will be donDistrie raccordant with. San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health' ct. <br /> Home owner or licensed agent's signature certifies the following: "I certify that'in the performance of the work for which this <br /> i 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 /> ithis permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant must, I r al 7k quire inspections. Complete drawing on reverse ide: c' <br /> Signed K d <br /> Title: Date: <br /> F R DEPARTMENT USE ONLY ❑ <br /> Application ccepted by � Area Stfc 466-6781 <br /> _ <br /> Lvdi 369-3621 <br /> Additional Comments: [] <br /> F Pit or Grout Inspection�by Date } — Manteca 823-7104 <br /> '*.: Final Inspection by Date ! 2- Tracy 835-6385 <br /> Applicant - Return capie .::~Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> -- FEE, BASE--�k...DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> `A} f <br /> - -- - - -^ 10/82500 - .. <br /> EH 13-24 REV. 10/82 <br /> r 14-26 4 k <br />