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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. jg:�a ti y L� <br /> Telephone (209)' 466-6781 . 1 <br /> GATE ISSUED <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Co "ipli <br /> d Tricate) <br /> s <br /> (described. <br /> licaion is hereby'made to the San°Joaquin Local'Hea1th District for a permit to construct and/or install the work herein <br /> This application is made in compliance with San Joaquin County Ordinance No. 549 for sew ge or No, 1862 for well/pump <br /> the Rules andRegulations of the San Joaquin Local Healt District, ,r � �T �4 " <br /> Address ivision Name <br /> _-Owner's Name 4_,&5-4 0<1�e— 'kddress ,14fe,y ram DWV& 4VG- Sr1Weae_Phone <br /> Contractor's Name F . License No, Phone C�biE� <br /> TYPE OF WELL/PUMP WORK:~ NEW WELL WELL REPLACEMENT DESTRUCTION <br /> -PUMP INSTALLATION (� SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE Q <br /> FOUNDATION 1. AGRICULTURE WELL OTHER WELL PITS/SUMPS Q� <br /> r <br /> INTENDED USE TYPE OF]WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I JIndustrial U open Bottom F-� Manteca Dia. of Well Excavation <br /> Domestic/Private ❑Gravel I Pack Tracy pia. of Well Casing p <br /> Public Ej Other. Delta Type of Casing <br /> Li Irrigation Approx. Eastern <br /> Depth Specifications !!! <br /> Cathodic Protection Depth of Grout Seal <br /> Geophysical Type of Grout q <br /> Other <br /> Surface Seal Installed by <br /> ! Repair Work Done ❑ Type of Rump H.P. State Work Done \ , <br /> i Well Destruction Wel l"Diameter ;� Sealing Material (top 50') _ <br /> Depth l Filler Material (Below 50') <br /> .41 <br /> l� TYPE OF SEPTIC WORK: NEW INSTALLAT•I0N U REPAIR/ADDITION i-1 (No septic.tank or seepage pit permitted if public sewer is <br /> tE available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 34feet: Water table depth <br /> SEPTIC-TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity YMethod of Disposal <br /> SEWAGE SYSTEM Distance .io nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ �J <br /> LEACHING LINE jJ No. & Length of lines Total length/size <br /> FILTER BED Distance'to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS C1 Depth Size Number <br /> SUMPS L Distance to nearest: Well Foundation Property Line <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 n <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. \1 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this n <br /> permit is iss I shall not employ any person in such manner as to become subject to workmant compensation laws of California." 4� <br /> Contractor' hir' r sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permi is s ue F,shall emp1 sons subject to workman's compensation laws of California." <br /> The i a c r all r uir d inspections. Complete drawing on reverse side. <br /> Sign Title: J Date: Z3 <br /> FO EPA MENT USE ONLY <br /> Application Accepted by ' Area Q 7 Stk 466-6781 <br /> Additional Comments: �] Lodi 1 <br /> Pit or Grout Inspection by Date 6Manteca 823-7104 <br /> Final Inspection by Date —Z�0 3 � Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Perm /services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> 1 <br /> FEE BASE AMOUNT DiJ€ AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> i. INFO " <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14=26 <br />