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APPLICATION FOR PERiMi T <br /> { <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CH PERMIT NO. 3 -!✓��� j <br /> Telephone (209) 466-6781 I <br /> DATE ISSUED 1 <br /> I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 well/pump j <br /> and the Rules and Regulations of the San Joaquin Local Health District. a/ � <br /> ,Q�6 �$�� ,�,(J Subdivision N me M✓ � � <br /> Jab Address ' <br /> Owner's Name L � ` Address '� Phone/� 35"^�� ; <br /> Con �i¢ <br /> tractor's Name � <br /> License No, Phone 7 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ] WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR F-1 OTHER U I <br /> � r <br /> DISPOSAL FLD. PROP. LINE 4 , <br /> t DISTANCE TO NEAREST: SEPTIC TANK -.15- SEWER LINES 1' <br /> F.OUNDAT•I,0N- / 7- -AGRICULTURE WELL .OTHER-WELL PITS/SUMP5 <br /> INTENDED USE- ,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEGbFICATIONS ^ �q <br /> IJ Industrial `" '[f'Open Bottom Manteca Dia, of Well Exca'vatiori ` <br /> LJ Domestic/Private []Gravel Pack Tracy �Dia.,of"Wehl Casing_ <br /> Puhlis [I Other Delta F f Type of Casing 1 1. <br /> Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> LJ Geophysical Type of Grout <br /> 0 Other Surface Seal Installed by <br /> Repair Work Done El Type of Pump <br /> H.P. State Work Done <br /> i` Well Destruction Well Diameters Sealing Material`(topy;50'`) - <br /> Depth Filler Material ,(Bew 50') �i s74X� f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITIseptic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence X Commercial Other <br /> Number of living units: Z Number of bedrooms 3 Lot size. &47 cd- J CD r <br /> Character of soil to a depth of'3 feet: �9 :. - Water table depth <br /> SEPTIC TANK L Type/Mfg Capacity \4a . • No. Compartments <br /> PKG. TREATMENT PLT. F-1 Type/Mfg %.> �. Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Dell ". Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of'lines ,`1 4 Total length/size-,_ . <br /> Distance to nearest: Well Foundation Property Line ° <br /> Ir' FILTER BED <br /> Number <br /> SEEPAGE PITS Depth �' _-, Size <br /> Property Line <br /> SUMPS �� Distance to nearest: Well Foundation L�_.-- <br /> DISPOSAL PONDS ❑ P /t/ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> t. <br /> ordinances, state laws, and'rules_and. regulations of,t he San Joaquin Local Health in the p <br /> Home owner or licensed agent's signature certifies the-following:�:'i certify that in the performance of i he work for which this <br /> permit is iss I shall not employ any person in such manner a5-to-become subject to workman' compensation flaws of California." <br /> Contractor's ing or sub-contracting signature certifies the following: "1 certify thai�in the-parf.orma�r eof-the workiLh= - <br /> this permit i i ued, 1 shall em p perso subject to work n's compensation laws of California." <br /> The applic s_t call f all uireo- • spe ions. Compl to d on reverse side. <br /> Date: <br /> Signed n <br /> Title: !Cp CJ <br /> FOR PARTM USE ONLY—­ jS . Stk 466-6781 <br /> ApplicaLion Ac4epted by -Y <br /> Area �� <br /> Lodi .' 369-3621 <br /> Add'i.tibnal Comment's:' <br /> ' Date Manteca 823-7104 <br /> Pit or Grout Inspection by <br /> ' <br /> Date /z-�- ❑ Tracy- 835-6385 <br /> Final Inspection by <br /> Hazelton Ave., P.O. Box 20D9, 5t k., CA 95201 <br /> Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. <br /> --- <br /> LEEWBA AMOUNT DUE� -~AMOUNT REMITTED �RECEItlED BY 1 ] ( DATE' -gPERM1T—N07 <br /> / la/sz 5aa <br /> EH 13-24 REV. 10/82 4k � /t <br /> ' 14-26 <br />