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Q 83-23 <br /> APPLICATION FOR.PERMIT ;. <br /> SAN JOAQUIN LOCAL.HERLTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> ! Telephone (209) 466-6781 DATE ISSUE <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, f <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 Re`�}}at'o S 01: the San Joaquin Local Health District. <br /> Job Address 11 L__" Subdivision Name . <br /> Owner's NamAddress Phone <br /> e � L � <br /> Contractor 's-Name- License No. 44 Phone <br /> TYPE OF—WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ V��? <br /> PUMP INSTALLATION -' SYSTEM REPAIR, R OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES + i +DISPOSAL FED. - PROP. LINE 1 <br /> .�_ FOUNDATION AGRIC URE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> IJ Industrial Lf Open Bottom Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack Tracy_ Dia.,.of Well Casing -- <br /> - ,�..... F-1_• +riu:._-.fes—•—'�..".w.- .. ie <br /> Public G Other Delta Type of Casing <br /> Irrigation Approx. Eastern Specifications <br /> Cathodic Pr tion Depth <br /> qte� Depth of Grout Seal <br /> Geophysical Type of Grout _ <br /> S <br /> Other 'Surface Seal Installed by <br /> Repair Work Done E] Type of Pump <br /> F-1Other <br /> H.P. �~ State-Work Done '� <br /> Well Destruction ❑ Well Diameter " Sealing Material (top 50') — <br /> Filler Material (Below 50') <br /> Depth 1: <br /> seweTYPE OF SEPTIC WORK: NEW INSTALLRTION } ( REPAIR/ADDFTION J (No septic tank or seepage p�availableewithid if nu200cfeet.) is ; <br /> ! r <br /> Installation will serve: Residence Commercial � ther <br /> Number of living units: Number of bedrooms Lot size <br /> Water table depth <br /> Character of soil to a depth of 3 feet: id <br /> SEPTIC TANK Type/Mfg L a 1)_f=)'��� — Capacity Q No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> Foundation— _ ...Property Line <br /> {•.<� SEWAGE;SYSTEM -Distance..ta nearest:''Well F <br /> F DESTRUCTION Q t y• - '� y <br /> h LEACH IN_G-�L-•I,NE�---No:-&-Length_o.f'.lines 'S ` Total length size i <br /> FILTER BED 'Distance'fd nearest: Well Foundation I Property Line t <br />` <br /> SEEPAGE PITS Depth r. .Size Number �e�0' <br /> Distance to nearest:} Well` Foundation Property Line tJ <br /> l SUMPS �I , <br /> DISPOSAL—PONDS­F—I"T <br /> . a�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 <br /> permit is issued, i shall not employ any person in such manner as to become subject to workman s compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fo116wing:""I'certi'fy'that•in the performance of the work for which <br /> his permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The app must Tl for a 1 req ire inspections. Complete,dd inglon reiverse <br /> sidgi Sign <br /> Title: J&LDate: <br /> r FOR DEPART _ D y r <br /> � Area 5tk 466-6781 <br /> Application Accepted by <br /> Lodi 369-3621 <br /> Additional Comment -/ - 3 Manteca 823-7104 <br /> Pit or Grout Inspection by s{�'� Date -^� <br /> � Final Inspection by <br /> Date Tracy 835-6385 <br /> / <br /> Replicant - Return all copie Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> 'a FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> R <br /> I INFO <br /> M 10/82 500 <br /> 0C__#_(4 w <br /> EH 13-24 REV. 10/82jay+r\ <br /> 14-26 <br />