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f <br /> a <br /> APPLICATION-FOR PERMIT . <br /> SAN JOAQUIN' LOCAL HEALTH DISTRICT 3� 'Q <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> PERMIT NO. QO 7 <br /> .Telephone (209) 466-6781 DATE ISSUED o <br /> `i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " <br /> (Complete in Triplicate) <br /> a' ermit total the wok hrein <br /> Application' is hereby <br /> madeotoithe <br /> San <br /> de iJoaquin <br /> Localce wth Health District <br /> fountyPOrdinance onNo5t549tfordsewagesorlNo. 1862rfore <br /> well/Pump 6 <br /> describe P <br /> and the Rules and-Regulations,of he San Joaquin Lor-21Health District. <br /> Job Address <r . ' Subdivision Name <br /> Phone <br /> Owner's Name Address <br /> R Phone <br /> Contractor's Name nse No. <br /> TYPE OF WELL/PUMP WORK: NEWWELL 1-1WELL REPLACEMENT ❑• .,; DESTRUCTION ❑ 4 t W <br /> PUMP INSTALLATION EJ SYSTEM REPAIR U OTHER U <br /> SEWER LINES DISPOSAL FLO, PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK L ELr•' � <br /> FOUNDATION AGRICULTURE WELL OTHER WPITS/SUMPS (� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS oO <br /> -❑ Industrial ❑Open Bottom ❑Manteca <br /> Dia. of Well Excavation <br /> Ll Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing <br /> ❑ Public Cl Other ❑ Delta Type of Casing <br /> `Y <br /> Irrigation Approx. ❑ Eastern Specifications <br /> Depth <br /> ❑ Cathodic Protection y _ Depth of Grout Seal ' <br /> L]Geophysical l Type of Grout <br /> U Other " ' Surface Seal Installed by n ,. <br /> of Pump H.P. state Work Done r�3 <br /> Repair Work Done ❑ Type.- _ -4— <br /> Well Destruction ❑ Well .Diameter . Sealing Material (top:50') <br /> Depth Filler Material (Below 50') `JU <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR ADDITION (No septic tank or seepage piavailableed if withinu200cfeet.) is <br /> lnstallation will serve: Residence Commercial Other <br /> Num of bedrooms Lot size <br /> Number of living units: - Water table depth <br /> Character of soil to a depth of m3 feet: No. Compartments <br /> SEPTIC TANK f_1Type/Mfg` Capacity __.��_ <br /> Capacity Method of Disposal <br /> PKG. TREATMENT PLT, F-1 Type/Mfg, <br /> Line <br /> SEWAGE SYSTEM ❑ Di stancelto.•nearest; Well -- <br /> Foundation. _ -_ ,Property., <br /> DESTRUCTION 0` 4 <br /> Length of lines <br /> No. & Len 0 . Total length/size <br /> LEACHING LINE � 9 Property Line <br /> FILTER BED Distance to nearest:- Well /p o -Foundation <br /> SEEPAGE PITS Depth 1� 'Size <br /> 4 I Number N, <br /> SUMPS Distance to nearest: Well 10 O ' Foundation <br /> Property Line <br /> DISPOSAL PONDS D G <br /> I hereby certify that I have prepared <br /> thif.apl <br /> hJoaOinthewLocaliHealthcrk-wll bedDistric one in accordance with San Joaquin county `- <br /> or which this <br /> ordinances, state laws, and rules 4that <br /> Home owner br licensed agent's signature certifies <br /> the follow nos to becomeysubjectntohwopkman�compensationwlawsf <br /> d of California." <br /> suc <br /> permit is issued, I shall not employ any per <br /> son j Contractor's Hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 00, <br /> The applicant must 11 for all wired inspectio s. Complete drawing ron reverse side. Date: [/ t� <br /> Signed X Title: �y <br /> " OR ARDENT USE ONLY Area C/ e— �[ Stk 66-fi781 <br /> .,_.r Application Accepted by s --� <br /> c ❑ Lodi 359-3621 <br /> Additional Comments: f,��� fig! ❑ Manteca 823-7104 <br /> Po <br /> I or Grout Inspection by Date -�-_-Z--= <br /> _ Date /Ulu ❑ Tracy 835-6385 <br /> Final Inspection 11 by <br /> e <br /> Applicant - Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 <br /> DATE PERMIT NO. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY nq <br /> INFO A 3 $3_-`I VO <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />