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f <br /> APPLICATION FOR PtRMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1501 E. HAZELTON'AVE-, STOCKTON, CA PERMIT NO. �S <br /> Telephone'('209),466-6781 j <br /> a DATE ISSUEDty�_ w <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "'•z• ,� , { <br /> f (Complete in Triplicate) ' t <br /> IIS # <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 7 <br />' and the Rules and Regulations,of the San Joaquin ll Local Health District. <br /> Job Address � �J rJ�9aP11 ,Lam/"-+ Subdivision Name <br /> Owner's Name � Q//� �� - Address <iv�f Phone �� 5 <br /> W <br /> Contractors Name /¢ 1s� '�: S _ License No. ly3Lj'Z Phone <br /> n <br /> TYPE Of WELL/PUMP WORK: NEW IWELL ] :WELL REPLACEMENT E] DESTRUCTION ❑, tj1 <br /> i <br /> ' PUMP INSTALLATION SYSTEM REPAIR OTHER -[J- <br /> DISTANCE <br /> DISTANCE TO NEAREST: SEPTIC TANK--- SEWER LINES DISPOSAL FLD.' PROP, LINE <br /> ( FOUNDATION AGRICULTURE WELL OTHER WELL 9 .:P.ITS/SUMPS, <br /> k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # � <br /> 'F] Industrial ❑ Dpen16ottom Manteca Dia. of Well Excavation <br /> t <br /> i U Domestic/Private Gravel Pack -Tracy Dia, of Well Casing 9 <br /> ❑ Public E] Other E] Delta,.. T »� <br /> ,. ype of Casing <br /> [_j Irrigation Approx. [� Eastern <br /> �e th Specifications <br /> N <br /> F0 Cathodic Protection p Depth of Grout Seal I <br /> Geophysical Type of Grout <br /> jJ Other . <br /> � .5 Surface Seal Installed by` <br /> Vepair Work Done �J Type of Pump' H.P. State Work Done <br /> Well Destruction F-1Well Diameter Sealing Material (top 50') I <br /> Depth Filler Material, (Below 50') <br /> TYPE OFISEPTIC WORK: NEW INSTALLATION jJ REPAIR/ADDITION.- (No septic tank or seepage pit permitted if public sewer is <br /> i <br /> . available-within 200 feet.} <br /> installation will serve. Residence _ Cammer Commercial Other 1 <br /> *r '` <br /> Number of living units: Number off bedroomb '_ ' t size ty, <br /> Character of soil to a depth of3 feet: t Water table depth / <br /> SEPTIC TANK Type/Mfg LCapacity 'No. Compartments <br /> • is <br /> PKG. TREATMENT PLT. T e/Mf Capacity Method of Disposal <br /> n <br /> r rt <br /> SEWAGE SYSTEM D-Es�tance to'.nearest: `Wel h�. Foundation' P o e <br /> p y <br /> Line <br /> DESTRUCTION ❑ i i <br /> If. LEACHING LINE No.s, <br /> & Length of lines _-_ m <br /> Tot"1 len th size t' <br /> FILTER BEODistance to nearest: Well Foundation Property Line . _ ,, <br /> F t <br /> SEEPAGE:PITS ❑ Depth Size iNumber: <br /> SUMPS j_j Distance to nearest: Well Foundation o F �Property Line <br /> A C. <br /> DISPOSAL PONDS • 'Al- n <br /> I hereby certify that 1 Piave 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 /> I� a.� j <br /> Home owner or licensed agent 's signature certifies the:followin9:1'" certify that°,imithe performance of the work for which this <br /> permit .is issued_+-.I shall not erggl,oy any person in_such rranrier as to become subject to workman compensation laws of California." <br /> Contractor''s hi rig or sub-contracting s.igna�ure cert'ifies"the,fo,l'low.rig:R; certify that in the performance of the work for which <br /> this permit;i ssued, Iishall employ rsons ject to workman' mpensation laws of California." <br /> The apQlic t u `call for 1 re d i tions Complete ra g on rev r?fside. <br /> Signed X Title: Date: <br /> l ,rw` FOR_'DEPARTMENT.-USEtONLY-- '_' <br /> Application Accepted by <br /> 1„,;w , .F it p« - >. —Are;+�' �' � Stk 466-6781 <br /> 'y � -,,.- <br /> 'Additional Comments: I S ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date c Manteca 823-71044 <br /> Final Inspection by Date �� ' 'L�Tracy 835-6385 <br /> Replicant -Return all cope Environmertal Health "Permit/Services 1601 E, Haze]ton Ave., P.O. Box 2009, 5t k., CA 95201 <br /> 1 I 'j <br /> FEE' BASE 'Y ""AMOUNT ' DUE"­- -AMOUNT-REMITTED—" —RECE-I'VED rBY _bATE =•-PERMIT.,-N . <br /> INFO <br /> FH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />