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30 V <br /> APPLICATION FOR PERMIT <br /> i <br /> SAN .iOAQt,II; LOCA' HEALTH D-:..ST <br /> RIOT PERMIT N0. <br /> 1501 E. HAZELTON AVE.,,STOCKTON, CA .3 <br /> Telephone (209) 466-6781 DATE ISSUED `� U <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; <br /> (Complete in Triplicate) <br /> rein <br /> Application is hereby made noishmadeSan <br /> inJoaquin <br /> complianceLocal <br /> wlithlth SanDistrict <br /> J Joaquin Countypermit <br /> Ordinance cNo, 5449tforand/or <br /> sewagesorlNo. 1862rforewell/pump <br /> described. This application <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> i1 Subdivision Name <br /> Joh Address Phone I 2-7 <br /> i <br /> 2 s S S <br /> Owner's Name � Address d Phone <br /> 1®D <br /> License No. <br /> Contractor's Name <br /> NEW WELL <br /> TYPE OF WELL/PUMP WORK: NEW REPLACEMENT DESTRUCTIONOTHER U <br /> PUMP INSTALLATION SYSTEM REPAIR PROF.. LINE <br /> WDISPOSAL FLD. ,, <br /> DISTANCE TO NEAREST: SEPTIC TANK ..SEWER LINES OTHER WELL PITS/SUMPS j <br /> FOUNDATION AGRICULTURE WELL ri1 <br /> CONSTRUCTION SPECIFICATIONS �,✓f,�} <br /> INTENDED USE TYPE OF WELL PROBLEM AREA Dia. of Well Excavation <br /> �� Industrial U Open Bottom 0 Manteca <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public [, Other Delta Type of Casing <br /> j Irrigation Approx. [] Eastern Specifications <br /> k Depth ,.. .Depth of Grout-Seal <br /> Seal <br /> Cathodic Protection �- , <br /> Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> H p State Work Done <br /> Repair Work Done G Type of Pump __ �- <br /> Sealing Material (top 50') ----� J <br /> Well Destruction U Well Diameter Filler Material (Below 50') <br /> Depth _ - -- <br /> REPAIR/ADDITION (No septic.tank ors.. pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U available within 200 feet.) <br /> Installation will serve: Residence P/ Commercial Other <br /> Number of Iivin Number of bedrooms <br /> units:9 � ) = Water table depth . <br /> Character of soil to a depth of 3 feet: /-A <br /> Capacity No. Compartments <br /> 1 �_�� <br /> SEPTIC TANK �A$ Capacity Method of Disposal <br /> PKG. TREATMENT PLT. Type/MfgY Foundation -�Property Line <br /> II SEWAGE SYSTEM Distance to nearest: Well F <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines <br /> Total length/size <br /> Foundation Property Line <br /> f FILTER BED Distance to nearest: Well --- <br /> IOe Number <br /> th _. _�� Size � <br /> 3 <br /> SEEPAGE PITS � p � .� � Property Line � <br /> U <br /> SUMPS <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS C} f l Ff <br /> ccordance with San Joaquin county <br /> 1 hereby certify that I have prepared this application and that the work will be done in a <br /> following: I certify that in the per of the work far which this <br /> r ordinances, state laws, and rules and regulations of'the San ,]aaquin-Lvcal Heal-th District. <br /> Home owner or licensed agent's signature certifies themanner <br /> the erformance of the work for which <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 yr sub-contracting ersvnsure subjectcertifies <br /> workman�sl�ompensationcertify <br /> laws ofthat <br /> California." I <br /> this permit is issued, I shall employ p <br /> The applicant must call for al required insp tions. Complete drawing on reverse'si <br /> Date: <br /> Title: <br /> Signed X Z <br /> I FOR DEP TME U5£ ON L1" n Stk 466-6781 <br /> Area �� <br /> Application Accepted by Lodi 369-3621 <br /> Additional Comments: Date Manteca 823-7104 <br /> Pit or Grout Inspection byDate /y Tracy 835-6385 <br /> Final Inspection by /y <br /> Applicant - Return all copies to: Environment health'Permit/Services 160 E. Hazelton Ave.,AP.O. Box 20St CA 95201 <br /> RECEIVED BY DATE PERMIT NO. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED (� <br /> INF© 1 �- <br /> �4� 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />