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Y a APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) DATE ISSUED i PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED (Complete in Triplicate) nit to Application is hereby made to the 'San iJoaquin Local with Heal th District Joaquin for a perp ncecNo . 549tfor dsewagelhrhereine work or No. ! described. This application is mide k and the Rules and Regulations of'the San Joaquin Local Health District. Job Address 33S4yZ- s• ��D-EL'�` "�� Subdivision N E Sy— S7K.✓ Phone G�Pf19 t Address E Owner's Name ,QRI72wly le License No. Phone 41�s Contractor's Name Name "! m6eq ' WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP WORK: NEl! WELL ❑ SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ DISPOSAL FL➢. PROP, LINE �_ ----�-----' DISTANCE TO NEAREST: SEPTIC TANKI__�� SEWER LINES OTHER WELL PITS/SUMPS f FOUNDATION ! AGRICULTURE WELL �� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Dia Industrial ❑Open Bottom Manteca . of Well Excavation r Dia. of Well Casing i -I Domestic/Private E]Gravel Pack ❑Tracy Public ❑Other ❑ Delta Type of Casing ❑ ff ❑ Irrigation E Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal Type of Grout [2 Geophysical (J 4 ❑Other Surface Seal Installed by T e of Pum H.P. State Work Done Repair Work gone ❑ yp P R -�— Sealing Material (top 50') well Destruction F-1Well Diameter Depth Filler Material (Below 50') d if sewer TYPE 4F SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION N (No septic tank or seepage pit availableewithin u200cfeet.) �s N Installation will serve: Residence _ Commercial _ Other (, .1Number of bedrooms Lot size Number of living units: Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Capacity Method of Disposal (J PKG. TREATMENT PLT. E] Type/Mfg property Line C Distance to nearest: Well Foundation ---- �� Total length/size LEACHING LINE LJ/ Mo.'& Length of lines FILTER BED E] Distance to nearest: We]] �-_ Foundation Property Line �O SEEPAGE PITS � Depth y�1 Size 3 `r Number ! i ± SUMPS [-j- Distance to nearest: Well Foundation _i91-- Property Line 0 DISPOSAL PONDS ❑ . i t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. followiHome owner or licensed agent's signature crties the mannernas to becameysubjectthat ntohworkman 5ncompensatnce of i�onwlaws fof California," permit is issued, I shall not employ any person Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." y The applicant must call for all required ins tions. Complete drawing on reverse side. Signed X Title: Date: F DE TM USE ONLY OQ 5tk 466-67Bi Application Accepted by Area �3 ❑ Lodi 369-3621 4 Additional Comments: ❑Date Manteca 823-7104 Pit or Grout Inspection p� Final Inspection by Date �/ Z ❑ Tracy 835-6385 Applicant - Return all copi s nvironmental Health Permit/Services 1 O1 E. Hazelton Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ------------- i 10/82 500', EH 13-24 REV. 10/82 14-26 — -