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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 ISSUED
<br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED +
<br /> (Complete in Triplicate) `
<br /> +
<br /> Application is hereby made to the San Joaquln 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 Rulei,.and Regulations of the San Joaquin Local Health District, .
<br /> Job Address ;QA�e d=10
<br /> Subdivision Name
<br /> Owner's Name aef? (164004 flddress $ Phone
<br /> Contractor's Name Ce-19R, License No. a Phone
<br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION
<br /> .-,.,,,.,,.-—,.,,-.—-,..,_,,,,P_UMP INS,TALLATION—[]—SY.STEM-REPAIR.. —I---I-..»—OTHER—Q
<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 /> Industrial ❑ Open Bottom [] Manteca Dia. of Well Excavation
<br /> ❑ Domestic/Private Ej Gravel Pack E] Tracy Dia. of Well Casing t
<br /> Public , Other, ❑ Delta
<br /> LI
<br /> Irri anon Type of Casing 9 -- +Approz. � Eastern
<br /> F-1Secificat ons Cathodic Protection Depth P
<br /> {�Geophysical "^ .,, Depth of„Grout Seal `•
<br /> Other `"J -Type of Grout
<br /> f , sv �, 1,. 4r Surface,Seal Installed by y
<br /> Repair Work Done Type of Pump r H;p; a �y -
<br /> -� State Work Done E i
<br /> Well Destruction ❑ Well Diameter Sealing Material (topl501)
<br /> Depth Filler Material (Bel;W4501)
<br /> TYPE OFrSEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LJ (No'septic tank or seepage pit permitted if public sewer is Q
<br /> available within 200 feet.)
<br /> Installation will serve: ResidenceComml'rcial _ Other
<br /> Number of living units: Qumber of bedrooms '� Lot size
<br /> Character of soil to a depth of 3 feet: )t1 Water table depth
<br /> f/r
<br /> SEPTIC TANK '.Type/Mfg; , k Capacity _ No, .Compartments '
<br /> PKG. TREATMENT PLT. Type/Mfg, Capacity Method of Disposal k I
<br /> SEWAGE;SYSTEM Distance-'to ''nearest: Well I_ Foundation Property Line f',O T.
<br /> DESTRUCTION ❑ �.r.i.
<br /> r
<br /> LEACHING LINE No. & Length of lines Total length/size
<br /> FILTERiBED E Distance to nearest: Well Foundation Property Line
<br /> SEEPAGE PITS Cj Depth Size �`�� Number ,;,ms �^^ )
<br /> SUMPS ❑ Distance to nearest: Well ; Foundation Property Line ;
<br /> DISPOSAL'PONDS
<br /> s >S r
<br /> I hereby certify that`I have`pre'pare-d this application and that the work wi11 be done in accordance with San Joaquin county +"
<br /> ordinances; state laws, and rules and regulations of the San Joaquin Lqcal Health District.
<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,issued,',,shall.not-employ oany person -in such manner as to become subject-to workman� compensation-laws of California."
<br /> Contr'actor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which
<br /> this permit is issued--I„sfiall employ persons-.' to workman's cpmpensatioA 1 aws of California."
<br /> The applicant must call r al req 'r d inspections. Complete drawing on reverse side. 1
<br /> Signed.X_ . , Title: R Date:
<br /> ,�- FOR P TMENT USE ONLY e , /'
<br /> Application Accepted by. Area Of? �] 5tk 466-6781 )
<br /> k Add't' I Crnts: -, �'_j-_4 �.w;"' Lodi 369-3621 !
<br /> �` "'y p y Date �^ nteca 823-7104
<br /> Final Inspection by . Date `
<br /> 6 i Tracy 835-6385 f
<br /> Applicant - Return all copies+to: Environmental Health Permit/Services 601 E: Hazelton Ave., P.O. Box 2009, Stk., CA 395201
<br /> FEE' BASE AROUNT` DUE - A960-NT REMITTED RECEIVED�BY DATE PERMIT N0.
<br /> INFO `
<br /> EH 13-24 REV. 10/82 10/82 500
<br /> 14-26
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