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APPLICATION FDR PERV,1 <br /> APPLIC T , <br /> SAN JOAQUIN LOCA_ HEALTH DISTRICT <br /> AUG 2 X984 1601 ETelephLTOON(AVE.,4STOCKTON CA PERMIT N <br /> DATE ISSUED_= � y <br /> SAN JOAQUIN LOCAL PERMIT EXPIRES I-YEAR FROM DATE ISSUEO r <br /> HEALTH DISTRICT (Complete in Triplicate), <br /> l the <br /> rein <br /> Application is herebyhatetoitheSaniJoaquin Local -Hialthth District Joaquin fora pOrdinanaeconst uctfan sewage Sorlr <br /> ermit No. 1862for ewell/pump <br /> s made <br /> described. This app v <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Subdivision Name <br /> Job AddreskkAWU-5 , Phone %_�� <br /> Owner's Name y����� Pi'rr _ Address /g <br /> �s�se No. ,�k Phone <br /> Contractor's Name c1 <br /> WELL REPLACEMENT DESTRUCTION <br /> TYPE OF WELL/PUMP WORK: NE4! WELL OTHER l _ <br /> PUMP INSTALLATION SYSTEM REPAIR LJ DISPOSAL FLD PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK I& SEWER LINES OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS a <br /> w - INTENDED USE - = �TYPE-OF WELL (3� <br /> Diaof Well Excavation <br /> Industrial U .Open Bottom ❑Manteca <br /> Domestic/Private Gravel Pack Trac� Y Dia. of Well Casing <br /> _ <br /> k Pu 61ic D�Other Delta Type of Casing �� PJ1 I <br /> Eastern <br /> Lj Irrigation s Approx. ❑ specifications <br /> Depth .— <br /> Cathodic Protection DepDepth of Grout Seal/ <br /> Geophysical Type of Grout <br /> I <br /> LJ Other Surface Seal Installed by <br /> Type Pum H.P. State Work Done <br /> Repair Work Done EJ_ yP of p <br /> Well Destruction U 50'Well Diameter Sealing Material (top 50')Filler Material (Below 50') <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIDN El REPAIR/ADDITION LJ (No septic tank or seepage pit <br /> available ewithin d if u200cfeetsewer �s <br /> Installation will serve: <br /> Residence Commercial _ Other <br /> ` Number of living units: ",Number of bedrooms Lot size <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> F SEPTIC TANK F Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity <br /> SEWAGE SYSTEM 17 Distance to nearest: Well <br /> Foundation Property Line <br /> DESTRUCTION <br /> No. & Length of lines Total length/size - <br /> _W _ .LEACHING LINE u g Property Line <br /> FILTER BED � Distance to nearest: Well Foundation <br /> Size Number <br /> Depth V <br /> SEEPAGE PITS ❑ p Property Line <br /> SUMPS �� Distance to nearest: Well Foundation --� <br /> DISPOSAL PONDS <br /> 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 fal lows as to become subject that ntohwoprkmaon� compensation wlaws fof California." <br /> F permit is issued, I shall not employ any p "I certify that in the performance of the work for which <br /> Contraetor`s hiring or sub-contracting �r9onsusubjectre �toeworkman's s the lccompensatian laws of California." <br /> this permit is issued, I shall employ p <br /> The applican m st all far all required inspections. Complete dra ing on everse pate: <br /> 44v]?� <br /> Title: <br /> Signed X <br /> �;rARTMLNT USE OILY �r SJ 466-6781 <br /> ApplicationAre Accepted by Lodi 369-3621 <br /> l Additional Comments: Date Manteca 823-7104 <br /> f Pit or Grout Inspection by <br /> Date J-911 Tracy 835-6385 <br /> F' <br /> Final Inspection by <br /> Applicant - Return all copies to.: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bvx 2009, St k., CR 9 -� <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> DATE PERMIT NO. <br /> INFO <br /> 10/B2 500 <br /> LH 13-24 REV. 10/82 <br /> 14-26 <br />