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r-; <br /> APPLICATION FOR PERM.'T <br /> SAN JOAQb'i�',' LOCA!. HEALTu 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 <br /> Owner's Name — mess _ �3 � <br /> Contractor's Name License N6. Phone <br /> TYPE OF WELL/PUMP WORK: " NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> ' PUMP INSTALLATION SYSTEM REPAIR OTHER Lj <br /> DISTANCE TO NEAREST: SEPTIC TANK 490 f— SEWER LINES DISPOSAL FLD./W 'f' PROP. LINE � ' ` <br /> i. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE t'. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t <br /> K J Industrial S Ll Open Bottomanteca Dia. of Well Excavation <br /> i 9;06omestic/Private ravel PackD TracyDia�of Well Casing <br /> -. <br /> f] Public Other Delta <br /> `L , _ .,,. Type of Casing _Irrigation �""""""�(j Approx. � Eastern <br /> Specifications i <br /> Cathodic Protection Depth / stg, /� t <br /> Geophysical <br /> Depth of Grout Seal —0 ,477 <br /> I U Other _ TYP�?of Grout <br /> i Surface Seal Installed by I i r <br /> Repair Work Done Type of Pump H.P, w� State Work Done - <br /> Well Destruction U Well Diameter Seal 1in Material to 5O' = 'k <br /> - <br /> Depth <br /> (top } <br /> 3 -tea <br /> Depth Filler Material (Below 50') <br /> C TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITIONU (No septic tank or seepage pit p$rmitted if public sewer is <br /> F LI <br /> ! " _ .. — ­-'a available within 20D feet.) f <br /> Installation will serve: Residence Commercial k= Other ' <br /> 4 <br /> Number of living units: Number of bedrooms , Lot size <br /> Character of soil—to-a_depth.of,.3_.feet: Water table depth <br /> SEPTIC TANK I DI Type/Mfg Capacity No, Compartments r <br /> PKG. TREATMENT PLT. Type/Mfg $ Capacity •,.Method of Disposal 1 4 <br /> SEWAGE SYSTEM Distance to.nearest: Well Foundation Property Line <br /> DESTRUCTION0 <br /> LEACHING LINE iJ No. & Length of lines Total length/size <br /> 4 FITTER BED Distance to nearest: Well Foundation :T Property Line ^� <br /> + SEEPAGE PITS Depth ' Size Number <br /> J <br /> ,. <br /> SUMP$ _ �� Distance to!nearest: Well Foundation,- Property Line <br /> DISPOSRL PONDS f Cj""° " ; • max. .:- .�. F .a rte. . —_. - -� > 1� <br /> • .,,,fes-.- �:� �y,� <br /> I hereby certify that I have prepared tthis application and. that the work':will be done in accordance with San Joaquin county � + <br /> ordinances, state laws, and rules andregulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the fallowing: "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 subjec't�to workman!s compensation laws of California." <br /> Contractor's hiring p�'su--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 us ca - for' 1 required inspections. Complete d g on- r erse , <br /> Signed X Title: Date: A E <br /> FO TM USE <br /> I Application,Accepted by Area Stk 466-6781 <br /> Additional,i�Comments: Lodi 369-3621 \'t <br /> Pit or Grout Inspection by fir! Date Manteca 823-7104 <br /> t <br /> Final Ins pection'by. Date r L Tracy 835-6385 <br /> Applicant - Return-611 copies to. 3 Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, St k.,'CA 95201--- '' -- <br /> _. <br /> FEE BASE.."- •S AMOUNT PbUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0, <br /> INFO <br /> -7o aw 1y1 ji Irt"= <br /> x EH 13-24 REV, 10/82 10/82 500 <br /> 14-26 <br />