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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT w <br /> !� 1601 E. HAZEL70N AVE., STOCKTON, CA PERMIT NO. '��� <br /> S t'z�/e t <br /> Telephone (209) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED <br /> A9� (Complete in Triplicate) <br /> Application is.heaeblicateonoishmaderein <br /> ninocompliancelwithlSanth DJoaquin Countyistrict for a pOrdinanceermit to cNo. 549tfor dsewage sorl•Noth1862rfor ewell/pump <br /> described. PP <br /> and the Rules and.Regulations of the San Joaquin Local Health District. <br /> Job Address Subdivision Name <br /> Phone j <br /> ,r {i <br /> Owner's Name Address Phone <br /> Contractor's Name <br /> ;11 License No. <br /> NE1J WELL DESTRUCTION <br /> TYPE OF WELL/PUMP WORK: WELL REPLACEMENT ❑_ <br /> o- OTHER U <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> s � <br /> SEWER LINES DISPOSAL FLO. 10 <br /> PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ /� 4 PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL _ _ OTHER WELL <br /> � CONSTRUCTION SPECIFICATIONS �� 0 <br /> INTENDED USE TYPE OF WELL, PROBLEM AREA - Dia, of Well Excavation �- <br /> F—1 Industrial Open Bottom '❑ Manteca <br /> !ZZ ❑ <br /> Domestic/Private E]Gravel Pack Tracy Dia. of Well Casing <br /> It— Delta 7 e of Casing {' n <br /> Public Other,. ❑= ,,. yP _' I <br /> pec <br /> Eastern Specifications eV <br /> t <br /> Approx. <br /> " <br /> Lj Irrigation Pp ❑ > f <br /> ❑Cathodic Protecti6n Depth ,,,._Depth of Grout Seal <br /> 1 Type of .Grout, ,SA <br /> Geophysical k <br /> ❑Other Surface Seal Installed by <br /> Type of Pum H`.P: State Work Done <br /> Repair Work Done 0} yP p i�- — ' <br /> Sealing Materiall(top 50'} x t <br /> Well Destruction F-1 Well DiameterFiller Material (Below 50') - <br /> + Depth <br /> l No septic tank or seepage pit permitted if, public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ( available within 200 feet.) <br /> ,� .~ " <br /> Commercial Other <br /> Installation will serve: Residence Lot size <br /> Number of bedrooms r <br /> F Number of living units: Water tdble depth" <br /> Character of soil to a depth of:3 feet: Cap ity No. Compartments <br /> t " SEPTIC TANK Type/Mfg r Method of DisposalCapaci <br /> PKG. TREATMENT PLT. Type/Mfg Property Line s <br /> SEWAGE SYSTEM ❑ Distance to nearest:" Well <br /> Foundation p y <br /> DESTRUCTION <br /> Total length/size <br /> LEACHING LINE ❑ No. & length of lines Property Line <br /> FILTER BED <br /> ❑ Distance to nearest: Wel l Foundation .,, <br /> Depth Size'. Number <br /> SEEPAGE PITS Foundation Property Line <br /> SUMPS <br /> �� Distance to nearest: Wel l <br /> t 'DISPOSAL PONDS ❑ _ <br /> I hereby certify that I have prepared this aPPlnsaofothenSanhJoaquinLocalwork yHealll bthdDistricone in tccordance with San Joaquin county. s <br /> ordinances, state laws,.and rules and regulatio compensation laws of California. <br /> { Home owner or licensed agent's signature cerson7en suchs the fmannernas to becomea ubjectntohworkman formance fof the kthe rwork cfor hwhich <br /> i permit is issued, I shall not employ any p <br /> k[ P `�iaws�of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing: "I'certify that in e p <br /> this permit is issued, I shall employ persons subject to workman's tom ensation;._, �,_ .w <br /> I The applicant t call for all required inspections. Complete drawing on reverse side, Date: <br /> Title: (, <br /> ,if fill <br /> Signed X ❑ <br /> F DEPARTMENT U ONLY Stk 466-6781 <br /> Area �8 t <br /> f Application Accepted by F odi 369-3621 # <br /> € Additional Comments: Date �D {L] Manteca 823-7104 <br /> ff Pit or Grout nspection by y ❑ Tracy 835-6385 <br /> Date <br /> -.Return all copies:to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., <br /> tk., CA 95201 <br /> Final lnspection by <br /> Applicant PERMIT NO. <br /> t OATF <br /> FEE- BASE AMOUNT DUE AMOUNT6REMITTED RECEIVED BY <br /> INFO lli <br /> 10182 500 <br /> EH 13-24 REV. 10/82 •�'""`- v C <br /> 14-26 <br />