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APPLICATION FOR PERMIT
<br /> SAN JOAQUiN LOCAL HEALTH DISTRICT
<br /> 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. 3 1 _a 3 o
<br /> Telephone (209) 466-6781- {
<br /> " PERMIT EXPIRES I YEAR FROM OATS ISSUED DATE ISSUED I 1
<br /> (Complete in Triplicate)
<br /> -rrt.:.,y�. � -.-�••0....:.i. •�?k: :.,,♦
<br /> w 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,•s,ewage.orlNo. 1862 for well/pump
<br /> and the Rules and Regulations of .the San Joaquin Local Health District.
<br /> w, Job Address Subdivis ion,,Name r '
<br /> 7,! raj+ Ms
<br /> ,
<br /> Owner's Name " Address '
<br /> • � �i_ > c •'Phone
<br /> s Contractor's Name 4, v.0€v License Phone` f
<br /> S
<br />'1 TYPE OF WELL/PUMP.WORK: NEW WELL" . WELL.RE;PLACEMENT . DESTRUCTION LA
<br /> s PUMP INSTALLATION ' SYSTEM REPAIR
<br /> ❑ `•9, OTHER.'U r
<br /> I DISTANCE TO.NEAREST: SEPTIC TANK SEWER LiNE5 DISPOSAL FLD.ef PROP,. LhNE §
<br /> FOUNDATION C AGRICULTURE WELL OTHER WELL PTT5y5UMPS '
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION 1,PECIFiCATI0N5 ' .at•
<br /> �g
<br /> F 1 Industrial ,
<br /> _� U Open Bottom �Manteca Dia. of Well Excavation �%`•
<br /> LJ Domestic/Private Gravel Pack Tracy Dia. of Well Casing r �
<br /> Public Other Delta
<br /> irrigation Type of Casing i `
<br /> • g Approx. Eastern Specificatif £
<br /> Cathodic Protection Depth ons N
<br /> Geophysical Depth of Grout Seal 1.J
<br /> LJ Other Type of Grout
<br /> r 5urface`Se'al Installed'by f
<br /> Repair Work Done E.] Type of Pump H.P; = = State Work Done '.
<br /> well!Destruction U Well Diameter sealing Material..(top 50')
<br /> t Depth Fi11er Material
<br /> _.-s. -, ---TYPE~OF-SEPTIC-WORK: k wNEW .INSTALLAT:ION;0. REP-AIAR/ADDITION,I (Nonseptic tank or seepage"pi t'-permittedi f-public sewer~is - ,
<br /> a µ.. a4ailable within 200 feet.) a
<br /> Installation will serve: Residence Commercial Other l may,
<br /> Number of-living units: __ Number of'b'edrooms L"ot size �I F1�C x' ry
<br /> Character of soil to a depth of 3 feet: ����®£JG"`-i%I „ .a' Com;;'; ^`; Water table depth
<br /> S TIC TANK Type/Mfg i ! f _`
<br /> _�j L _ Capacity da• No. Compartments -
<br /> PKG. TREATMENT PLT. Type/MfgCapacity t k Method of Disposal
<br /> SEWAGE SYSTEM ��----11 Distance to nearest: Wel'i Foundationt,Pr-ope�ty Line
<br /> $ DESTRUCTION �—l t
<br /> LEACHING LINE No. & Length vf, lines /_�T T6ta7,' gth/si e'.
<br /> FILTER BED . Distance tolnearest: Wel lFoundAtion :. , pe`rty Line "
<br /> SEEPAGE PITS F-j Depthk Size ! ri Number t
<br /> SUMPS 1
<br /> �� Distance to nearest: Welh Foundation ) Property Line.
<br /> DISPOSAL y- -
<br /> PONDS
<br /> I hereby certify that I have prepared this appl-ication and that the'work'will,be4done_in accordance with San Joaquin county
<br /> ordinances, state laws, and rules andregulations of the San Joaquin Co caT Hea,l,tfi"Dist`rict "; j
<br /> Home owner..or licensed agent's signature certifies the fallowing: "I ,certify that in tiie performance of. the work fd'r whachrthis
<br /> permit is issued, I shall not,employ any person in such manner-es ,to,became subject to workman compensat ion.laws of.41 fornia., _
<br /> Contracto'r's hiring or sub-contracting signature certifies the'follbMhq:-,'I certify that in the performance of the:work for. Aihich-T°`" It
<br /> this permit is issued, I shall employ persons- subject to workman's compensation laws of California."
<br /> The applicant must cal or all required inspections. Complete drawing on reverse side. 4 ; ..
<br /> Signed X 4 Title:
<br /> k r
<br /> Date:
<br /> � R DE A TMENT USE ONLY
<br /> 1 Application Accepted by , Area s }
<br /> c Stk 466"6781
<br /> 4 # r u
<br /> Additional Comments: ( f Lodi 364-3621 f r ,
<br /> Pit or. Grout Inspection b 4823-7
<br /> p r A
<br /> P Y Date Manteca 823-7104 .
<br /> Final Inspection by Date ,A/ ❑ Tracy 835-6385 •.,� , y., * ' E
<br /> Applicant - Return all copies to: Environ , al Health Permit/Services 1501 E. Hazelton Ave., PA'Box 2009, Stk.;'CA '95201 ,`• I
<br /> t _
<br /> F FEE BASE AMOUNT DUE AMOUNT REMITTED
<br /> i• INFO RECEIVED BY DATE PERMIT N0.L4 JS
<br /> i t'
<br /> EH 13-24 REV. 10/82 I�Ir x'11' .1'w/� 10/82 500
<br /> 14-26 ,'
<br />
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