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»..yr <br /> i <br /> APPLICATION FOW PERMIT ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781. PERMIT NO. �J <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED f <br /> .(Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work-herein, <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for <br /> and the Rules.and Regulations of the San Joa9uin Local Health District. . <br /> Job Address SILO fail/pump <br /> Owner's Name Subdivision Name tj <br /> tyk Address 9 <br /> Contractor's Name Phone a� <br /> License No. �3 <br /> Phone _ <br /> TYPE OF WELL/PUMP WORK: NEW WELL <br /> WELL REPLACEMENT L DESTRUCTION I <br /> PUMP INSTALLATION (J` SYSTEM REPAIR f <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER <br /> SEWER LINES DISPOSAL FLD. <br /> FOUNDATION I AGRICULTURE WELLPROP. LINE <br /> OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE_,_ OF WELL <br /> Industrial PROBL_ EM AREA CONSTRUCTION SPECIFICATIO16 <br /> Lf Open Bottom Manteca N i <br /> (Domestic/Private � a Dia, of Well Excavation. <br /> ravel Packracy <br /> Public Dia. of Well Casing <br /> er <br /> Oth , <br /> I E Delta <br /> LjIrrigation Type of Casing P f. <br /> Cathodic Protection Depth ❑ Eastern Specifications ' <br /> Geophysical Depth of Grout Seal / <br /> hl Other Type of Grout <br /> Repair Work DoneLJ Type T Surface Seal Installed by <br /> of Pump N.P. <br /> Well Destruction L Well Diameter State Work Done <br /> ti <br /> Sealing Materia_1 (top 50') �-- <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION v <br /> E LJ (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence _ Commercial Other <br /> available within 200 feet.) <br /> _ <br /> Number of living units: Number of bedrooms Lot size <br /> Character of sail to. a depth of 3 feet: <br /> SEPTIC TANKType/Mfg Water table depth <br /> �' <br /> PKG. TREATMENT PLT. Type/Mfg Capacity No. Compartments F <br /> Capacity ------Method of Disposal <br /> Distance to nearest: Well Foundation <br /> t Property Line <br /> LEACHING LINE L No. & Length of lines <br /> FILTER BEDTotal length/size <br /> Distance to.nearest: Well Foundation <br /> 4 Property Line <br /> SEEPAGE PITS <br /> Depth q, Size <br />' SUMPS Number <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS Property Line <br /> I hereby certify that I have prepared this appTication 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 signa <br /> permit is issued, ture certifies the following: "I certify that in the performance of the work for which this <br /> I shall not employ any person in such manner as to become subject to workman+; compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the foil owing: "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 /> The applican must call, for al] - ' <br /> fired inspecti ns. Complete drawl on re a side. <br /> Signed X <br /> Title: ' i <br /> Application Accepted by <br /> R PART) N USE ONLY _ Date: Q <br /> Additional Comments: u Area 7❑ Stk 466-678I <br /> Pit or G [] Lodi 369-3621 <br /> y <br /> Final Inspection by Date Manteca 823-7104 <br /> Applicant - Return all copies to; Env.,ronmental Health Permit/ServicDeTracy85-63 <br /> es 1601 E. Hazelton Ave., P.O. Box 200385 <br /> BCA 95201 <br /> FNF <br /> ASE OUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> EH 13-24 REV. I0/82 Icy <br /> I4-26 L J�} 10/82 500 ��- <br /> 1. <br /> r <br />