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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT J� <br /> 1601 F. HAZELTON AVE., S70CKTON, CA <br /> PERMIT NO. 9 732-1 I <br /> Telephone (209) 466-6781 , a DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) { <br /> l the <br /> rein <br /> Application :ihihereb7icadeototithe <br /> San <br /> s made iJo quip ancelwHth15anth 0Joaquin County istrict for a p0 dinancceermit to cNo. 549tfor dsewage sorlNo. 1862rforewell/pump <br /> described. T pp <br /> and the Rules and Regulations of the an Joaquin Local I District. <br /> Job Address r A`fes ubdivision Name <br /> / 0 �� / Phone r" <br /> 5 ! f <br /> Owner's Name Phone <br /> Contractor's Nam ft License No. <br /> WELL REPLACEMENT- DESTRUCTION <br /> NEW WELL Lf <br /> TYPE OF WELL/PUMP WORK: OTHER U _ __ ---� <br /> PUMP INSTALLATION �" SYSTEM REPAIR l� Ni LINE - 4 <br /> c SEWER LINES DISPOSAL FLU- <br /> DISTANCE`TO NEAREST: SEPTIC'TANK Y OTHER WELL PITS/SUMPS r <br /> FOUNDATION AGRICULTURE WELL �..,_ IN <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 'INTENDED USE TYPE OF WELL I <br /> 0 Bottom J Manteca Dia. of Well Excavation <br /> I� Industrial U pen 4. Dia. of Well Casing <br /> U Domestic/Priva-te-:.--.� —[].Gravel 'Pac'k- � Tracy K � <br /> i Public Other-t,,.,;,,. Delta Type of Casing <br /> " "�`" <br /> �"" �"JA rox. Eastern Specifications <br /> LJ Irrigation "`"""°"""""`•� Depth❑ c <br /> El Cathodic. Prot ection4 Depth of Grout Seal <br /> Geophysical Type of Grout <br /> Other S . �-. i '". t 4 Surface Seal Installed by <br /> Type of Pump mp H.P. State Work Done-, <br /> Repair Work Done [J <br /> 1 <br /> Well Destruction U Well Diameter Sealing Material (top 50') �J <br /> Depth Filler Material (Below 50') ^J <br /> .-��*�- available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U EPAIR/ADDITION No septic tank or seepage pit permitted if, public sewer is <br /> Installation will serve: Residence Commercia Other Lot size <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> 4 Capacity, <br /> �T e/Mf *. .. <br /> -a `SEPTIC TANK hyo. �. 4 yp- • g j Capacity �__tMethod df Disposal <br /> PKC. TREATMENT PLT. Type/Mfg 'Property Line § v t <br /> . :.'s .h. �.-...:;~t .Foundation. t <br /> SEWAGE SYSTEM �-Distance to neares <br /> Well <br /> DESTRUCTION . <br /> Total 1 ngth/size <br /> LEACHING LINE No.. & Length of lines �_�� l ` <br /> �. 2 Property Line <br /> FILTER BED Distance to nearest: WellFoundation 1 <br /> Depth ��__ $1Ze Number f! <br /> SEEPAGE PITS [J Foundation Property Line <br /> SUMPS �� Distance to nearest: Well <br /> DISPOSAL PONDS �1 <br /> I hereby certify that I have Prepared regulations the an Joaquin the work, Healthwill be dDistric onLin ccorda ce with San Joaquin county"r <br /> ordinances, state laws, and rules ' <br /> Home owner or licensed agent's ork for which this <br /> signature cerson1ein suchFinannnernas to become subjectntohworkman� compensatance of �ianwof laws <br /> the California. <br /> permit is issued, I shall not employ any p the <br /> Contractor's hiring <br /> or Iubb-contractingpsignatuons subject�toeworkman�slrompensationrlaws ofrCalnforniaerformance of the work for which <br /> this perm " h <br /> ` ll <br /> The applic must call for all required inspecti s. Complete drawing on reverse side. pate: <br /> Title: <br /> Signed X <br /> DEPARTMENT USE ONLY Stk 466-6Y11/9- <br /> FOR <br /> Area <br /> 1 Application Accepted y Lodi 369-3621 <br /> Additional Comments: Date Manteca 823-7104 <br /> � L-1 <br /> Pit or Grout Inspection by Date /1� Tracy 835-6385 <br /> Final Inspection by <br /> t <br /> Applicant - Return all copies to: Environ a al Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> PP <br /> RECEIVED BY r DATE PERMIT NO. <br /> FEE BASE MOUNT DUE AMOUNT REMITTED <br /> INFO <br /> 10/82 500 <br /> ( LH 13-24 REV. 10/82 <br /> 14-26 <br />