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APPLICATION FOR PERM: <br /> SAN '04QL1" LOCAL HE-,LTH D-STRICT SEP <br /> 1661 E. HAZELTON AVE" STOCKTCA O J —/63_3 <br /> Telephone (209) 466-6781 <br /> PERMIT NO. U <br /> 1 � + I-9 <br />� PERMIT EXPIRES 1 YEAR FRDATE ISSUEDOM DOTE ISSi( '/},�i = <br /> (Complete in Triplicate) <br /> k Applicatior 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 far sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local ealth District. ;y <br /> Job Address g ���,J �+ <br /> � Subdivision Name 4jG9L(J/'i� <br /> Owner's Name J 'L AJ(, Address 5.�/1i"� <br /> Contractor's Name �y Phone <br /> ✓License No, p2"/ df Q �1 <br /> Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT <br /> DESTRUCTION ❑ �� <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE To NEAREST: SEPTIC TANK SEWER LINESW <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE <br /> PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A <br /> !J Industrial_ -.� ❑ Open Bottom Manteca �- <br /> ❑ Dia. of Well Excavation C> <br /> I—] <br /> ❑ Gravel Pack Trac <br /> ❑ Public - y Dia, of Well Casing <br /> CjOther ❑ Delta <br /> LjIrrigation Type of Casing <br /> Approx. Eastern <br /> Cathodic•Protection- Depth - - - Specifica.t.ions,•_. <br /> Geophysicai\_ c Depth of Grout Seal `"",--- <br /> U Other ' ` >�t Type of Grout <br /> '' . ? Surface Seal Installed by <br /> Repair Work Done . pe'of,Pumpk jR State Work Done <br /> Well Destruction ❑ Well Diameter; Sealing 'Ma"aerial (top 50') <br /> DepthFiller Material (Below' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION D (No septic tank'or_seepage pit permitted if public sewer is <br /> Installation will serve:, Residence Commercial _ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: ' Water table depth -� <br /> SEPTIC TANK FJhype/Mf y,. <br /> PC/Mfg Capacity No. Compartments <br /> -PKG: TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM""'- <br /> DESTRUCTION ❑ Distance-to-near_es.t: 'We 1,1. Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Cj Depth Size <br /> Number <br /> SUMPS ❑� Distance to nearest: Well Foundation Property Lune <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work wiTh,be done, accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations.,of�the San,Joagl�9n'Local-,Health District, <br /> Home owner or licensed agent's signature certifies the following: "I'cer•t'ify`•that in�'the performance of the work for.which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmans,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 California. <br /> The appl=all f al equired in Complete drawg on reverse side. <br /> Signed X C,S�/f)4 p <br /> Title: Date: <br /> A TM T US LY 1 <br /> Application Accepted b Area Q to Stk 466-6781 <br /> Additioral Comments: 9 Lodi 369-3621 <br /> Pit or Grout Inspection b \ Date Manteca 823-7104 <br /> Final Inspection by _ 11� Dat <br /> Tracy 835-6385 <br /> Applicant - Return all copies to: Environmenta edlth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED DY DATE PERMIT NO. <br /> INFO <br /> �3 3 <br /> EH 13-24 RFV. 10/82 j�� 10/82 500 <br /> 14-26 r• i/� - <br />