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APPLICATION FOR PERMIT 3 SAN JOAQUiN LOCAL HEALTH D15TRiCT PERMIT N0. r II 1601 E. HAZELTON AVE., STOCKTON, CA d i Telephone (209) 456-6781 DATE ISSUED Q PERMIT EXPIRES 1"YEAR FROM•DAT 55UED k (Compl ete"in,.'Tri pl icaY�!} .� �. d Application"is'hereb madeiotoithe San de iJo quip ancel'HealSanDistriit for ountyPOrdinanccermit to e No. 549tfor dsewage sor.No. 1862rfor ewell/Pump described. This app and the Rules-and Re wit (is(is of e San Joaquin Local Hea th District. 3 �� ubdivision Name Job Address Phone GJ Address Phone Owner's Name � "iI No. Contractor's Name icense pb WELL REPLACEMENT DESTRUCTION TYPE OF WELL/PUMP WORK: i NEW WELL / OTHER 1 PUMP INSTALLATION 0 SYSTEM REPRIR lids L DISPOSAL FLO. PROP. LINE L DISTANCE TO NEAREST; SEPTIC TANK I�O — SEWER LINES PITS/SUMPS FOUNDATION RI CULTURE WELL �•_� OTHER WELL INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS = Op n Bottom [] Manteca Dia of Well Excavation rY J 1 ustrial Dia. of Well Casing estic/Private `tivvel Pack Tracy , Public �F—j Other El Delta V Type of Casing , Approx. Eastern Specifications Lj Irrigation' Depth 0— Cathodic Protection Depth of-Grout Seal 9 � �GeopType of Grout physical — Other Surface Seal Installed by HJT , �, H p State Work Done Repair Work Done �T YPe of Pump vII Sealing Material (top 501) Well Destruction ❑ WelllDiameter ��— Filler.-Material (Below 501 �3 Depth wer TYPE OF SEPTIC WORK: NEW INSse TALLATION U REPAIR/ADDLFTION U (No septic tank or seepage P�availableenn withiu200cfeet�} is if j — '•� Other j Installation will serve: Residence Comme-rc�a�l'� Lot size �_�— Number of living units. Number of beorns Water table depth, Character of soil to a'�depth of,3 feet: Capacity _ No, Compartments T e/Mfg " SEPTIC TANK [—I Type/Mfg Capacity �.� Method of"Disposal PKG. TREATMENT PLT. [} Type/Mfg Foundation" Property Line l SEWAGE SYSTEM I Distance to nearest: Well �� t DESTRUCTION Ss Total length/size LEACHING LINE ❑ I No. & Length of lines Property Line I Foundation FILTER BED ❑ �� Distance to nearest: Well M Size Number SEEPAGE PITS ❑ Depth —�-- Property Line ,_1 � " SUMPS ��" Distance to nearest: Well Foundation DISPOSAL PONDS be in ance I hereby certify that 11 have prepared this application and that the work willaiththatdon the performance ofhthe nwork�for-which uin ythis ordinances, state laws;i and rules nattureregulations certifiesothe followie San ong. L11 certifyethat District• compensation laws of California." _ Home owner or licensedlagent's sig erformance of the work for which' permit is issued, I shall not employ any persore n in such manner as to become subject to workmathe n comp ontractor's hiring or'sub-contracting signatusubject�toeworkman's s the lcompensation rlaws oftify aCal�ifornia." this permit is issued,��I shall employ p Complete drawon reverse side. The applicant m st cal or all required inspections, p pate: t� _ , Title: Signed X 0 Stk 465-fi781 F R DEPARTMENT USE ONLY Area �. 7= Xy Application Acchpted by Lodi 369-3621 i Additional Comments: Date J7 $ " 0 Manteca 823-7104 —� 835-6385 Pit o<2>Inispection by Date f,2' �" L Tracy 4 CA 95201 Final InspectioFn by G, �Ct:Ss�h°) •'� Applicant - Return all copies to' nvio nmen 1 �P�h Permit/Services 1 01 E• H�zelton ,.P•0• Box 2009, 5 VJ 1J DATE PERMIT NO. �J AMOUNT REMITTED RECEIVED BY FEE BASE AMOUNT DUE — ' INFO � 10 500 J + r� EH 13-24 REV. 10/92 L 14-26 fr