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APPLICATION FOR PERM!; <br /> SAN JDAQLiN LOCAL HEALTH UiSTRICT3 S <br /> 1601 E. !A7ELTON AVE., STOCKTON, CA PERMIT N0. <br /> 4 <br /> Telephone (209) 466-6781 PATE ISSUED <br /> 5 <br /> PERMIfr'XP,IRES 1 YEAR FROM DATE ISSUED R <br /> (Complete in Triplicate) <br /> to <br /> rein <br /> Application is hereby made oishmadeninocomplia�celwilthlth San'Joaquin Countyistrict for a permitOrdinance cNo. 549tfordsewagesorlNoth1862rforewell/pump <br /> described. This application11 <br /> and the Rules and Regulations of the San Joaquin ocal Health District. /�/�y 1` <br /> r� Subdivision Name IRZ -57 <br /> Job Address a0r3 Phone <br /> Address �. <br /> Owner's NamePhone <br /> Contractor's Name r r License No. hh <br /> NEW WELL WELL REPLACEMENT DESTRUCTION <br /> TYPE OF WEIL/PUMP WORK: <br /> U <br /> PUMP INSTALLATION (� SYSTEM REPAIR ❑ PROP LINE <br /> LINES DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TRNK SEWER OTHER WELL PITS/SUMPS r <br /> FOUNDATION AGRICULTURE WELL rt— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIQN SPECIFICATIONS <br /> en Bottom Manteca Dia. of Well Excavation <br /> J Industrial U Op Dia. of Well Casing V <br /> U Domestic/Private J Gravel Pack J Tracy <br /> h- <br /> [],Public [—IOther �..;{Q Delta Type of Casing <br /> A ,...r_. Specifications <br /> E ❑ Irrigation Dep ❑ <br /> J Cathodic Protection Depth Approx. Eastern Depth of Grout Seal�. <br /> Geophysical Type of Grout <br /> IJ Other Surface Seal Installed by <br /> State Work Work Done <br /> Repair Work Done G Type of Pump H.P. <br /> Well Destruction U Well Diameter <br /> Sealing Material (tap 50') <br /> Depth Filler Material (Below 50') <br /> r No septic tank or seepage pit permitted if public sewer is OI <br /> ° TYPE OF SEPTIC WORK: NEW INSTALLATION LSI REPAIR/ADDITION ( P available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Lot size <br /> Number of living units: Number of bedrooms <br /> Water table depth 444 <br /> ' Character of soil to a depth of 3 feet:! ' No. Compartments �L <br /> SEPTIC TANK Type/MfgG CapacityZx <br /> Capacity Method of Disposal l <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Property Line <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation <br /> DESTRUCTION <br /> Total length/size <br /> LEACHING LINE No. & Length of lines r^ r <br /> t FILTER BED J Distance to nearest-.' Well <br /> .� Foundation "" Property Line �— <br /> Size Number <br /> SEEPAGE PITS Depth �- Property Line <br /> SUMPS J Distance to nearest: Well Foundation y <br /> DISPOSAL PONDS "❑ >lc�d l <br /> ' I hereby certify that I have prepared this atponsaofothenSanhJoaquinwLocalork �Healll bthdDistrioone in tccordance with San Joaquin county <br /> i ordinances, state laws, and ru 9cerperformance of the work for which this <br /> Home owner or licensed agent's signature certifies <br /> thesucfollow nos to becomeysubjectntohworrkman� compensation laws of California"" <br /> permit is issued, I shall not employ any p <br /> contractor's hiring <br /> ing or <br /> sub-contracting <br /> ub-c ntractingl employ psignaturons ubjectso ltoeworkman'slccompensationrlaws ofaCalifornithe a.°fvrmance of the work for which <br /> this permit <br /> The applicant u tic 11 f r requi d spections. Completedr in n never, side. pate: S <br /> Title: <br /> Signed <br /> FO EPARTMENT USE ONLY. Area _ Stk 466-fi7$1 <br /> Application Accepted by Lodi 369-36-21 <br /> Additional Comments: ----- Zlo �3 Manteca 823-7104 <br /> Date Date G L <br /> Pit or Grout Inspection by 7 Tracy 835-6385 <br /> Final Inspection by <br /> Applicant - Return all copies to: Environmental Health Permit/Services 160 E. Hazelton Ave., P.O. Box 20D9, Stk., CA 95 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED By <br /> DATE PERMIT N0. <br /> INFO <br /> I �. 10/32 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />