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00 <br /> APPLICATION FOR PERMIT <br /> k <br /> APS 2 J r p SAN ,IOAQL;N LOCAL H.-_ALT; DISTRICT <br /> I�G 4 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, <br /> Telephone (209) 466-6781 <br /> SAN JO AQUIN LOCAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> HEALTH DIST-RICT (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 well/pump <br /> and the Rules and�eguiations of.the San Joaquin Lo al Health District, <br /> Job Address 1� _A�_ S, S&%1r0AV—kl Subdivision Name "C JFJ <br /> Owner's Name L T j74cf?Address Phone <br /> Contractor's Name T%V- License No, 2"01_Q Phone�_���}� <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO.; PROP..,LTNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS --� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS £ <br /> F1 Industrial U Open Bottom [1 Manteca Dia. of Well Excavati¢n. " P <br /> Domestic/Private Gravel Pac'kiP �,❑ Tracy ," , Dia, -df-,W <br /> ell Casing ,r <br /> F <br /> Public ❑Other Delta ! , <br /> Type of Casingrft <br /> C Irrigation Approx. ❑ Eastern - <br /> Specifications <br /> Cathodic. P'rotection's '.- Depth <br /> M a <br /> Depth of'Grout Seal ^^ k <br /> Geophysical'; _ Type of'Grout <br /> U Other Surface Seal Installed by <br /> Repair Work-Don'e' Type'-ofK-Pump+ jig H.P. f State Work Done <br /> Well Des.trdction.0 .iWelI' Diameter Sealing Material' (top 50') <br /> ~ Depth filler Material'(Below 50') i A <br /> TYPE OF;SEPTLC WORK`:•+NEW-INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available .wi.thin,200..feet,_),,,,,__­ <br /> Installation +will :serve•:- Residence _ Commercial Other <br /> Number of living, units: Number of bedrooms Lot size <br /> Character of soil-'t�o,a depth of 3 feet: Water table_depth X44. ,`#f.Y" <br /> 41 <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments } <br /> PKG. TREATMENT PLY. Type/Mfg Capacity Method of Disposal C{� <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property line <br /> DESTRUCTION ❑ A i <br /> w <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> E � <br /> FILTER BED Distance to nearest:—Wel.l.r ._-~-_.--F.oundati.ona Property Line <br /> SEEPAGE PITS F-1 Depth S1 ze,'�4 ': 's Number c <br /> SUMPS ❑ Distance to nearest: Wellj Foundation Property Line <br /> DISPOSAL PONDS C� <br /> I hereby certify that I have prepared this application 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.', 1 F <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work.fdr which this <br /> permit is issued, 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 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 Cal-ifornia." <br /> The applica must all for requ' d inspections.. Complete dr wing on reverse side. <br /> Signed X Title: Date:_ <br /> FOR DEPAR ENT U F ONL , } <br /> Application Accepted by1w40— Area [] Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by A--- `^— Date Manteca 823-7104 ` <br /> Final Inspection by 11C2 Date ❑ Tracy 835-6385 <br /> Applicant - Return all copi%t;-/ <br /> t . ironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> t <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY i5DATE PERMIT NO. f <br /> INFO <br /> VZ 0 <br /> EH 13-24 REV. 10782 ` qb 10/82 500 <br /> 14-26 <br /> k <br />