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APPLICATION FOR PERMIT ?- j <br /> SAN JOAQUIN LOCAL HEALTH D15TRICT PERMIT N0. U` — <br /> 1601 E. HAZELTON AVE., STOCKTON, CA +q <br /> Telephone (209) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR'FROM DATE I55UE0 ^< <br /> (Complete in Triplicate) .. <br /> Apelkation is hereby ma.de��,to"th.11 e San Joaquin Locate Health District far a permit to construct and/or install the work herein <br /> described. This applicdfj.nnE.. made in compliance with San Joaquin County Ordinance No. 549,for sewage or Na: 1862 for well/Pump <br /> and the Rules and Regula�6ns of the San Joaquin vocal Health District. <br /> ubdivision Name p ne -7 J <br /> Jab Address ��3r� '7y+� YL <br /> Address Phone <br /> Owner's Name �y # <br /> Contractor's,Name <br /> License <br /> y DESTRUCTION :d <br />( TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT OTHER U <br /> PUMP INSTALLATION (� SYSTEM REPAIR L� PROP LINE <br /> 4 �.SEWER�L-INES- �- r �* DISPOSAL FLD. <br /> DISTANCE NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL - _ __ _ - <br /> I - <br /> - -- CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE . TYPE OF WELL PROBLEM AREA <br /> IJ Industrial U Open Bottom Manteca <br /> Dia. of Well Excavation <br /> U Domestic/Private Gravel Palk <br /> Tracy Dia. of Well Casing <br /> Public` Other Delta Type of Casing <br /> Irrigation <br /> A rox. Eastern ` Specifications ` <br /> � u r PP <br /> Depth Depth of Grout Seal <br /> I Cathodic Protection <br /> Geophysical � � � . . . . _ � � Ty Pe of Grout <br /> Surface-Seal Installed by <br /> LJ Other <br /> W <br /> Type of Pump H.P. ^�' State Work Done <br /> Repair Work Done G u t, — <br /> Well Destruction U Well Diameter Sealing Material-(top 50') <br /> e Depth Filler Material (Below 501 <br /> 7_7iti ermitted if public sewer his <br /> No septic tank or seepage p P <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADI"I� I ( _ a Zlable within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ other <br /> size <br /> Number <br /> ��r S <br /> Number of living units: Number of bedrooms Lot Water table depth <br /> Character of soil to a depth of 3 feet: Capaci � No. Compartments <br /> SEPTIC TANK Type/Mfg Capacity Method of Disposal <br /> t �_-� <br /> PKG. TREATMENT PLT. Type/Mfg Foundation Property Line <br /> f SEWAGE SYSTEM Distance to nearest: Well <br /> DESTRUCTION �.� <br /> Total length/size <br /> LEACHING LINE U No. & Length of lines <br /> FILTER RED Distance to nearest: Well <br /> ' Foundation Property"Line <br /> / X umber <br /> SEEPAGE PITS Depth — _ S'I Property Line <br /> €oundation <br /> ,SUMPS L-1 Distance to nearest: Well �Q� � !_ <br /> [ DISPOSAL PONDS ❑ rt r <br /> tI hereby certify that I have prepared this app <br /> lication 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 /> erti3'4,Zgome owner or licensed agent's..signature cersonien suchthe fmannernas to become subjectthat ntohwopkmanb coepformancewofensation wthe f orkryfor nwhich <br /> permit is issued,'�I shall not employ any phe <br /> `t hi er'mi.ts"ishiring <br /> issued, Iushalltemploygpersonssignature <br /> subjectcertifies <br /> workman'slcompensationrlaws ofaCal�ifornithe a." <br /> 5a'A 1 �J <br /> I The applicant sf call for 1 r ed s ons. Complete drawing on reverse side. Date. 3O3 <br /> Title: <br /> Signed X N <br /> FOR DE RTMENT' SE ONLY �.�• � .5tk " 4b6-6781 <br /> % m .. ail,,,, "_ Z Area <br /> Application Accepted by �. Upt�� Lodi 369-3621 <br /> Additional Comments: Date �U Manteca 823-7104 <br /> Pit or Grout Inspection by .-'V Tracy B35-6385 <br /> Date ." �� <br /> Final Inspection by <br /> • - Return all copies o: £nviro • ental Health Permit/Services 1601 EH zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant <br /> RECEIVED BY DATE PERMIT N0. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED <br /> INFO O11 <br /> 10/82 500 i <br /> £H 13-24 REV. 10/B2 <br /> r 14-26 <br />