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APPLICATION FOR PERMIT,„ -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZELTON AVE_ STOCKTON, CA 'PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE I55llED <br /> PERMIT EXPIRES 1 YEAR FROMIDATE ISSUED- . <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local 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; <br /> Job Address-7ZZ6 (,�y�,,�`~� J Subdivision Name <br /> Owner's Namei`r /V ( 61, Address '' Phone <br /> Contractor's Names ,c ��[.1, License No Phone <br /> T � <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> ( PUMP INSTALLATION E] SYSTEM REPAIR OTHER ❑' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLO. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL QPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ` ❑Open Bottom F-1 Manteca Dia. of Well Excavation <br /> U Oomestic/Private Gravel Pack Tracy y Dia. of Well Casing <br /> j� Public - []Other [] Delta I <br /> Irrigation - A Type of Casing <br /> g Approx. Eastern t <br /> � P �, '� Specifications <br /> f F-1Cathodic.Protection Depth <br /> :4X. Depth,ef Grout Seal <br /> Geophysical ` n <br /> „ J Type of Grout <br /> f U Other 6` t S <br /> urface Seal Installed by ((`` <br /> # Repair Work Done ❑ Type of Pump H.P. StaWWork Done <br /> } <br /> Well Destruction F-1 Well Diameter Sealing Material (top 50':) t <br /> Depth Filler Material (Below 50') i I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDfTI.ON 'L (No septic tank or seepage pit permitted if public sewer is <br /> p available within 200 feet.) <br /> Installation will serve: Residence Commercial Other a <br /> Number.of living units: �_ Number of bedrooms t-1ot1size : <br /> Character of sail to a depth of 3 feet: / DD�� ! it <br /> Water table depth <br /> 4 SEPTIC TANK Type/Mfg L3J ,- ° Cap- acicity _ �No. compartments <br /> PKG. TREATMENT PLT. Type/Mfg :�t Capacity jMethod of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Wel lr Foundation �� Property Line <br /> DESTRUCTION ❑ . v i ti`_ .. +.� !D <br /> LEACHING LINE No. & Lengthoflines Total length/size. IC <br /> FILTER BED �] D' starice to'nearest, Well sFoundation Property Line, <br /> SEEPAGE PITS Depth 4,6­1 Size ` �,:t' .. Number ` <br /> a6- <br /> SUMPS U DistaY n,cue^to.nearest: _Wel l /Qty/- J!l undationF� Property Line 9 Q' <br /> DISPOSAL PONDS <br /> I,herfeby rtify that I have prepared this application and that the work wifll bAone in accordance with San Joaquin county <br /> drdinances, state laws, and rules and regulations of, the San Joaquin,Lgcal ,Health"District: <br /> E ` Roane owner or licensed agents signature certifies-the,followi•ng: "I certify that,in the performance of the work for which this <br /> permit is issued, I shall not employ any person in°"such:'manner_a. s to become subject to workman t compensation laws"of California." <br /> Contractor's hiring or sub-contracting signature certifies the following. ":'I'cert;ify that in the performance of the work for which <br /> f E this permit is issued. I shall employ persons subject to workman's compensation laws of California." <br />! The applicant must call fo all required inspections. .Complete drawing on revers side. <br /> } Signed X / ..="� '""'"",.."` _Title:`_""" Date; <br /> € DR AD � <br /> U NLY <br /> t Application Accepted b Areg Stk 466-6781 <br /> E Additional Comments: E Lodi 369-3621 <br /> i� ate Pit or Grout Ins ection „ Manteca 823-7104 <br /> P Lam . <br /> Final Inspection by � � eM��.v, Date Tracy 835-6385 <br /> Applicant -Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Bax 2009, Stk., CA 95201 <br /> --- ---FEE----BASE-.---AMOUNT--•DUE- - ,'---AMOUNT-REMITT ED-w RECEIVED BYDATE_ -- PERMIT NO., <br /> INFO' y�.S ",v <br /> " <br /> , <br /> EH 13-24 REIO/82500 <br /> REV. 10/82 <br /> 14-26 <br />