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1 3 <br /> � t <br /> APPLICATION FOR-PERMIT <br /> SAN JOAQUI UCAL,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 /> "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 - /QV Subdivision Name <br /> Owner's NameuTko@.�__ Add ess � <br /> Phone <br /> Contractor's Name �d�`^F �' ._ License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` ; D1SSPOSAL_FID.. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/5UMP5 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS` <br /> Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation <br /> i <br /> Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing s <br /> i g <br /> ❑ Public ❑Other ❑ Delta T pe•of Casing ? <br /> irrigation � Approx. Eastern <br /> Depth ." p. <br /> ecifications 11 7q <br /> ❑ Cathodic Protection ;'Depth <br /> f <br /> of Grout Seal <br /> Geophysical _ Typt of Grout <br /> ❑Other # <br /> � Surtace Seal In stalledby <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction F-1 Well rDiameter Sealing Material (top 50') <br /> Depth ! Filler Material (Below •50'1 r <br /> TYPE-OF"SEPTIC"WORK:YNEW INSTAI:C) IT oN.. ..Z EjA'IR/ADDITION-❑`"(No-septic`tank`or seepage piL7Vp mitted if'publ`ic-sewerAs­ <br /> r !,available within } <br /> 200 feet.) } <br /> Installation 4511 serve: Residence Commercial — Other r k '4 <br /> r,� S <br /> Number of living units: _-4— Number of bedrooms Lot size !Y ';" -„ i <br /> -A 3 `Wa <br /> Character of soil to a depth of*�•feet: a-t3� ter table depth <br /> r <br /> SEPTIC TANK ❑ Type/Mfg � , __ Capacity "� No. Compartments. �1 <br /> PKG. TREATMENT PLT. E] Type/Mfig ': 1 ~ 'Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest:Well Foundation� 1--Properrty Line <br /> DESTRUCTION ❑ I 1 I <br /> LEACHING LINE ❑ No. & Length of lines ^' , �T,otal-len th/sa•ze•' U F i <br /> : 1 Foundation—Propert Line <br /> F14TER BED [] Distance:to nearest: Well /!lb P '�. <br /> SEEPAGE PITS ❑ Depth Size ~Number' y a <br /> 1 <br /> SUMPS ❑ Distancee to nearest: Well/ t�) <br /> Foundation w4TJ>f ^P4 Property Line <br /> DISPOSAL PONDS ❑ a} <br /> I hereby certify that I have prepared this application 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 /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this S <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California. <br /> Contractor'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 shall employ persons subject to workman's_compensation laws of California." ; •� <br /> The applicant must cal fo a r ired inspections. Complete drawing on reverse side. <br /> Signed XTitle: Date: _+ <br /> x�r DRTMENT USE ONLY. i' J <br /> Application Accepted by l/dr I - _Area ..Q ❑ Stk 46b-6781 ;yy <br /> F ❑ <br /> Additional Comments: •� � Lodi - 369-3621 <br /> --.,Pit or Grout Inspection by Date ❑ Manteca 823-7104 <br /> f Final Inspection by Date ❑ Tracy 635-6385 } <br /> eaith-Permit/Services-1601 E•:-Hazelton-Auer-P:O -Box 2009;-5tk:,�CA-r95 <br /> Applicant`L.Return�-d�ll.-copies-•to,--Environment201e - <br /> FEF BASE AMOUNT DUE AMOUNT EMITTFO�! ' �: RECEIVED'BY .y ,'S% DATE PERMIT NO. <br /> \. INFO - - <br /> 7 <br /> p ~ <br /> EH 13-24 R&V. 10/82 10/82 500, <br /> 14-26 k <br />