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A APPLICATION FOR PERT T <br /> SAN JOA.QUiN LOCA'_ HEALTH DISTRICT ) J <br /> t 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 3 <br /> F Telephone (209) 466-6781 DATE ISSUED o� <br /> I .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' ' . <br /> j" r (Complete in Triplicate) <br /> . Application is ereb ma a to t e an oaquin Local'Heal th-0istrict fora permit to construct and/or install the work herein <br /> described. This application is made it compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of hS J apuin�LLooca ealth District. <br /> s - g <br /> Job Address Y' ��� Subdivision Name <br /> Owner's Name Il?1 Address *45Tr_0 57 -� . Phone i p <br /> Contractor's Name License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION OQ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ' I� IndustrialU Open Bottom Manteca Dia. of Well Excavation <br /> ` LJ Domestic/Private Gravel Pack { Tracy Dia. of Well Casing <br /> Public Other ID Delta Type of Casing <br /> Irrigation Approx. Ej Eastern , Specifications Depth — at - <br /> Cathodic Protection p { <br /> Depth of Grout Seal <br /> 1]Geophysical ` ; t <br /> U � Type of Grout <br /> Other <br /> Surface Seal Installed 6y <br /> Repair Work Done ❑ Type of Pump } H.P. State Work Done <br /> €:€3Sr: <br /> Well Destruction.U Well Diameter Sealing Material {top 501} <br /> Depth • ' "`s Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/:ADDITION Lf (No septic tank or seepage pit permitted if public sewer is <br /> I iv— ava]lable�wFthin 00 feet.) <br /> } Installation will serve: Residence Commercial Other -�33{{,�� <br /> Number of living units: Number of bedrooms Lot size r�E�� <br /> t <br /> Character of soil to a depth of 3:feet: Water table depth b <br /> SEPTIC TANK Type/Mfg a '._ RAk&JS Capacity 7jQW No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg a Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to.nearest: Well Foundation Property jin <br /> `. DESTRUCTION ❑ , <br /> LEACHING LINE a No. &'Length of lines-¢ Total length/size <br /> FILTER BED Distance to nearest: Well Foundation 1_57' Property Line <br /> SEEPAGE PITS Ej Depth. Size. Number <br /> § SUMPS 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 i such manner as to beconn"subject to workman compensation laws of California." <br /> Contractor's h'ring or sub-contracting si natur c rtifies the following:- "t�certify that in the performance of the work for which <br /> this permit i issued, I shall employ n subj ct to workmaji's compensation laws of California." <br /> i The applic t c l..for 1 requ e i ct• ns. Complete d' reverse side. / pnti <br /> Signed X e: I Date: �^ s <br /> 1 DEPARTMENT USE ONLY <br /> moo/ <br /> Replication Accepted by Area Stk 466-6�B1_ _ <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspectio b Date w. Manteca 823-7104 <br /> Final In by Date ❑ Tracy 835-6385 <br /> I. Applicant - Return all copi o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITN0. <br /> IN <br /> INFO. <br /> ov <br /> EH 13-24 REV. 10/82 10/82 500 <br /> - 14=26 <br /> s <br />