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D <br />APPLICATION FOR-PER'i'_T p <br />SAN OAQ�iN LOCAL HEALTH DISTRICT PERMJI NO. gS ~ ! (00 <br />1601 E. HAZELTON AVE 4STOCKTON, CA g>—Ik_`13 <br />Telephone (_ ) DATE ISSUED <br />PERMIT EXPIRES i YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />e to No. 1862 far well/pump <br />Application is'heaeb}}cade toithe <br />Saiide; in compliance Joaquin <br />Local <br />wNthlSanDJoaquin County pOrdinance ocNo. 549tfor dsewageor the work herein <br />described. This pp <br />and the Rules and Regulations of thle San Joaquin Local Health District. <br />-S Subdivision Name M-11 _4r -� <br />Job Address O Phone <br />L Address Phone <br />Owner s Name License No. <br />Contractor's Name <br />i <br />NE4J!WELL WELL REPLACEMENT IL] DESTRUCTION U <br />TYPE OF WELL/PUMP WORK: ;: SYSTEM REPAIR 01 OTHER <br />PUMP INSTALLATION ❑ DISPOSAL FLO.PROP. LINE <br />DISTANCE TO NEAREST: SOUND ATION SEWER LINES PITS15UMP5 <br />FOUNDTANK ! AGRICULTURE WELL OTHER WELL <br />TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit perfflit­ <br />available <br />it n 2 0 ee <br />available within 200 feet.) <br />r ^ <br />Installation will serve: Residence Commercial Lot_"size Q z/ e 49PO '�� <br />Number of living units: <br />Number of bedrooms Water table depth <br />Character of soil to a depth of 3 fe F Capacity d No. Compartments <br />/,� 1. <br />M■ <br />SEPTIC TANK <br />TYPE OF WELL <br />AREFI <br />CONSTRUCTION SPECIFICATIONS <br />....:-INTENDED USE <br />0 enigottom <br />U. p <br />—PROBLEM <br />Manteca-rA� i <br />Dia. of Well Excavation <br />Industrial <br />Gravel Pack <br />[jTracy <br />Dia. of Well Casing <br />U Domestic/Private <br />SEWAGE SYSTEM <br />Public <br />Other <br />7-1 Delta <br />Type of Casing <br />LJ Irrigation <br />Rpprox. <br />Eastern <br />Specifications <br />!Depth <br />Cathodic Protection <br />4 f Total <br />Depth of Grout Seal <br />Geophysical <br />LEACHING LINE <br />Type of Grout <br />I" <br />Prope ne <br />Surface Seal Installed by <br />LJ Other i <br />Distance to -nearest: <br />State Work Done <br />Repair Work Done ❑ <br />Type -of Pump' <br />H P. <br />Sealing Material <br />(top 50') <br />Well Destruction F-1 <br />Well Diameter <br />Filler Material <br />(Below 501) <br />Depth <br />SEEPAGE PITS <br />TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit perfflit­ <br />available <br />it n 2 0 ee <br />available within 200 feet.) <br />r ^ <br />Installation will serve: Residence Commercial Lot_"size Q z/ e 49PO '�� <br />Number of living units: <br />Number of bedrooms Water table depth <br />Character of soil to a depth of 3 fe F Capacity d No. Compartments <br />/,� 1. <br />M■ <br />SEPTIC TANK <br />-;&I <br />Type/ Mf9 <br />Capacity <br />. Method of DIsposa <br />PKG. TREATMENT <br />PLT. ❑ <br />Type/Mfg <br />Foundation <br />Property Line <br />SEWAGE SYSTEM <br />Distance to nearest: <br />Well <br />, .�.. U <br />d <br />DESTRUCTION <br />4 f Total <br />length/size <br />LEACHING LINE <br />No. &Length of lines <br />Foundation <br />Prope ne <br />FILTER BED <br />Distance to -nearest: <br />Well <br />Size <br />Number <br />SEEPAGE PITS <br />Depthl_-��_-- <br />Well <br />Foundation <br />Property Line <br />SUMPS <br />Distance to nearest: <br />DISPOSAL PONDS ` ❑ 11t <br />`i <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br />"I certify that in the performance of the work for which this <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 following: <br />permit is issued, I shall not employ any person in such manner as to become subject to workmanh compensation laws of California. <br />Contractor's hiring or sub-contractingpersonsusubject}toeworkman6sl�ompensationrlaws oftify aCalnforniathe erformance of the work for which <br />this permit is issued, I shallemploy <br />The applicant must ll for all required inspections. Complete dr ing on reverse side. Date: I iS <br />Title: <br />Signed X <br />F pEp MENT USE ONLY, � Area rR�- Stk 466-6781 <br />Application Accepted byS �] Lodi 369-3621 <br />—4- - Additional Comments:�r Date j� Manteca 823-7144 <br />Pit or Grout Inspection by U 9 Fj Tracy 835-6385 <br />Date <br />Final Inspection by <br />01 <br />Applicant' Return all copies�to: Environmental Health Permit/Services 1601 E. Haze]ton Ave-, P.O. Box PER2DOMIT <br />LA 952 <br />TSNO. <br />AMOUNT REMITTED RECEIVED BY DATE <br />FEL BASE AMOUNT DUE �rll- ]-[�,i „Q <br />7 Cid <br />tl Cly-�1•� 10/B2 500 <br />EH 13-24 REV. 10/82 <br />14-26 <br />