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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT �� V <br /> 1601 E. HAZELTON AVE., STOCKTON, CA z 1 <br /> Telephone (209) 466-6781 PERMIT NO. U 1 <br /> PERMIT EXPIRES 1 YEAR FROM GATE ISSUED DATE ISSUED <br /> f)-,(Complete in Triplicate) <br /> described. ThiseapplicationoishmadeninocompliarcelwithlSanHeathDJoaquin County P�-;;!�Ordinato construct54 9 fand/or <br /> install <br /> the work <br /> herein um <br /> }.' and the Rule �yn� Regulations of the San Joaquin Local Health District. pump <br /> Job Address <br /> v � <br /> Subdivision'Name <br /> 't{+ Owner's Nam r <br /> Address <br /> f Contractor's Name Phone Z!& <br /> License No. 2- Phone <br /> F <br /> M TYPE OF WELL/PUMP%ORK: <br /> NEW WELL L] WELL REPLACEMENT � DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESU <br /> DISPOSAL PLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> 'OTHER-WELL <br />' -- --.- _ __ PITS/SUMPS <br /> NTENDED USE - __. __ <br /> TYPE OF WELL PROBLEM AREA _-CO `0 <br /> CONSTRUCTION SPECIFICATIONS ' <br /> f IJ Industrial U Open Bottom Manteca <br /> LJ Domestic/Private Dia, of Well Excavation <br /> Public q <br /> []Gravel Pack L Tracy Dia. 0-` Well Casing / <br /> Other <br /> �J D Delta <br /> L ! Irrigation Approx f'N- Eastern Type of Casing <br /> Cathodic Protection Depth Specifications } <br /> Geophysical Depth of Grout Seai' - .; 4 Via" / l <br /> U Other Type-of-Grout <br /> s Surface Seal Installed by — <br /> Repair Work Done Type of Pump H.P. <br /> State Work Done <br /> Well Destruction — <br /> Welt D' , <br /> lame <br /> U ter- Sealing Material '°(-top-50'-) <br /> Depth ._ Filler Materia l•=(Below 501) - 1 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage it <br /> • p permitted if public sewer is <br /> Installation will serve: Residence Commercial Other available within' 200 feet.) W <br /> Number of living units: Number'of bedrooms <br /> Lot size <br /> Q7, !� <br /> Character of soil to a epth-of 3 feet <br /> - .� ' Water-table depth E. /�� <br /> SEPTIC-T•ANK- <br /> ���[ Type/Mfg Capacit No. Compartments <br /> PKG. TREATMENT PLT. Type]Mfr i - G ,- <br /> apacjty� Method of�Disposal <br /> SEWAGE SYSTEM 1-� Distance to nearest: Well , YY �k <br /> DESTRUCTION �"!"`_ Foundation propbrty L.in.e Y 5' <br /> ti <br /> LEACHING LINE U- No.,& Length of lines - �.- - <br /> Total length/size <br /> FILTER BED Distance to nearest: Well.. oundatibn f <br /> ' roperty Line <br /> SEEPAGE PITS Depth w ^� <br /> SUMPS I p o2 Sizes[~ �( !- � Numb r- <br /> �� Distance to nearest: Well /�A l,�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 th <br /> I shall not em ' e fallowing: "I certify that in the performance of the work for which this <br /> permit is issued, ployany 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 warkman's'compensation laws of California." <br /> The applicant t call for all equ'red inspections. Complete drawing on reverse side. <br /> Signed K @ Title: <br /> Date: a <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Area , EJ Stk 466-6781 <br /> Additional Comments: <br /> I Lodi 369-3621 <br /> Pit or Grout Inspection b Date Manteca 823-7104 <br /> Final Inspection by Date Lj Tracy 835-6385 <br /> 1 <br /> Applicant -'Return all copies o: Environ ental Health Permit/Services•"1601 WHzelt-7ve'., P.D. Box 2009, St k., CA 95201 <br /> 1. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> � s � <br /> EH 13-24 REV. 10/82 <br /> 14=26 10/82 500 <br />