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w <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, C IT N0. <br /> r Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED MAY 3 1 1984 DATE ISSUED <br /> l.vS10 S - S?—vcewcj 5 j (Complete in Triplicate) SAN JOAQUIN LOCAL_/oo—off <br /> Application is hereby made to the San Joaquin Local Health District for a permit IlFest+rUtt+k *TrG�all 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 O <br /> and the Rules and Regulations of the San Joaquin L al Health District. <br /> Job Address_I1(,UI, C.rrp" 8>L.A1'Eg_,j Subdivision Name <br /> Owner's Name Address Phone <br /> Contractor's Name License No. Phonee/. JIB <br /> TYPE OF WELL/PUMP WORK: NEW WELLWELL REPLACEMENT <br /> �] DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER �f" <br /> DISTANCE TO NEAREST: SEPTIC.TANK _ - - SEWER LINES j <br /> ,.�_ ---- (7 Y7;, _DISPOSAL FLU. PROP. LINE ) CO) C <br /> FOUNDATION AGRICULTURE WELL OTHER WELL -fes- PITS/SUMPS - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industria] 0 en Bottom <br /> U p ❑Manteca Dia. of Well Excavation <br /> j� Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public [j Other ] Delta <br /> [€ Irrigation Approx. Eastern Type of Casing <br /> ❑ Cathodic Protection Depth Specifications <br /> ,Geophysical _ <br /> Depth of Grout Seal <br /> LJ Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. ""` State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> kA <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [J REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is c <br /> Installation will serve: Residence _ Commercial Other available within 200 feet.) <br /> Number of living units: Number of bedrooms Lot size i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK [j Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal t i <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE [J No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS [J Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <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. + <br /> Home owner or licensed agent's signature certifies the following: "I certify 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 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 California." <br /> The appi4ca4t rgust call for a equired inspec ions. Complete dron reverse side. <br /> Signed X Title: « <br /> / Date: <br /> Application Acce ed by C/�� TME ONLY Area -Z_ Stk 466-6781 <br /> Additional Comments: ` edi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date '/G EJ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton F ., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> EH 13-24 REV. 10/$2 <br /> 14-26 •'/ ; 10/82 500 <br /> ry+ <br />