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APPLICATION FOR PERMIT <br /> SAN JOAQLiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTCN, CA PERMIT NO. <br /> Telephore (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM•DATE ISSUED DATE ISSUED <br /> rt <br /> (Complete in Triplicate) <br /> Application is' hereby made to'the San Joaquin•Lccal Health District for a 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 of the San Joaquin Local Health District, a <br /> Job Address 320 .-N. Cluft Avenue. Lod ubdivision Name <br /> W <br /> owner's Name Stub'S Paint & Body Address 320 N. Clutf Ave p T•ndi•"_ Phone t_ <br /> Contractor's Name Goehring Pump License No. 309031 Phone 727-554$ <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U f <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 /> F] Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation <br /> ❑ Public ❑ Other Delta Type of Casing <br /> Lj Irrigation Approx. Eastern �' Specifications <br /> EJ Cathodic Protection Y Depth .Y <br /> Depth of Grout Seal <br /> Geophysical <br /> y -Type of Grout <br /> Other <br /> Surface Seal installed by <br /> Repair Work Done [1 Type of Pump H.P. State Work Done <br /> We11,Destruction)M :Well Diameter 14" Sealing Material,(to p'.50') C Ont r e te_ <br /> Depth 250' Filler Material .(Below 50'} washed gra,y'e1 �} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U'.(No septic tank or seepage pit permitted if public sewer is Z <br /> i available within 200 feet,) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of_1_iving units: Number of�6edroorns = 'Lot size"�"�" <br /> __water tahl,e depth <br /> th <br /> SEPTIC TANK Type/Mfg s- s Capacity No. Compartments r <br /> PYG. TREATMENT PLT. Type/Mfg r " .. , ' ' } _ Capacity Method of Disposal } <br /> SEWAGE SYSTEM Distance to�nearesi7:�,Tdell y FoundationProperty Line <br /> DESTRUCTION ❑ .ti: ' ? 'jJ <br /> LEACHING LINE U No. & Length�ofilines-=-'�- -�- Total length/size <br /> F J <br /> FILTER BED Fl Distance to nearest: Moll Foundation' Property Line <br /> - r <br /> SEEPAGE PITS Cj Depth +j5,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. i <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issue shall not employ any person in such manner as to become subject to workman$ compensation laws of California." <br /> Contractor's or sub-contracting signature certifies the following: "I certify that in the performance of-the work for which <br /> this permit ed . I shall employ persons subject to workman's compensation laws of California." <br /> The app lic for all required inspections. Complete drawing 'on reverse side. <br /> Signed x Title: Blip _ Date: 02/27Z-B6 <br /> FORR. DLPARTMENT USE ONLY <br /> Application AcceptJ by Area ❑ Stk 466-6781 <br /> Additional Comments: l Lodi 369-3621 <br /> Pit or Grout Inspection by Date _ Manteca 823-7104 <br /> Final Inspection by � -� , Date L Tracy 835-6365 <br /> Applicant - Return all copies to; nmenta'T Health Permit/Services 1601 E. Hazelton Ave. 0. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. i <br /> INFO <br /> -173 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />