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:w APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -1601 E. HAZELTON AVE., STOCKTON, CA <br /> PERMIT NO. <br /> Telephone (209) 456-6781 DATE ISSUED <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Jaquin l the <br /> Application is herebycateonmadi oishmadeninocompliancelwlithlDistrictth permit <br /> SanJoaquin CountyOrdinance cNo. 549tdforsewage sorlNo. 1862rherein <br /> forwell/pump <br /> described. This app <br /> and the Rules <br /> /and Regulations of pthe. San Joaquin Local Health District. <br /> Job Address p( aN7 !+ 62V Subdivision Name <br /> � �y Phone <br /> O <br /> Owner's Name Address Ca 01 <br /> Phone <br /> Contractor's Name .�i +u-� License No. <br /> t <br /> WELLREPLACEMENT DESTRUCTION ~ ' <br /> NEW WELL ' U s <br /> TYPE OF WELL/PUMP WORK: ❑ OTHER U Vis° N <br /> PUMP. INSTALLATION L] SYSTEM REPAIR PROP LINE <br /> ISEWER LINES DISPOSAL FLO. <br /> DISTANCE TO NEAREST: SEPTIC TANK D7HER WELL PITS/S-UMPS <br /> FOUNDATION l AGRICULTURE WELL -� <br /> CONSTRUCTION SPECIFICATIONS t <br /> INTENDED USE TYPE �OF WELL PR08LEM AREA Dia of Well Excavation <br /> Industrial U Oped 8attot� ❑Manteca— <br /> u Domestic/Private Gravel Pack F1 Tracy Dia. of Well "Casing <br /> Public Other Delta Type of Casing # <br /> Li Irrigation " ' AA. ;Appro x Specifications <br /> 4 Depth ' Depth of Grout Seal <br /> Cathodic Protection <br /> t�Geophysical f fix- (" " r' Type of Grout ( <br /> U Other Surface Seal Install-ed by <br /> I 1.� H. P r <br /> _ State alork Done,^'' <br /> Repair Work Done Q Type of Pump '+ <br /> i Sealing Material (top 50'} <br /> ,Well Destruction ❑ Well Diameter x . . I <br /> t " f171 Eller Material (Below 50') <br /> -gam Depth <br /> r ' <br /> epage�Pl-t,�eratatted�i.f—pukla c sewer i s� <br /> `"TYPE-IIF�SPTIC'WORK: 1 WIf157&LLF1�" U4+- "E�s'IRfA�i �DN={ =FWo` P available within 200 feet.} <br /> e i <br /> Installation will serve: ' Residence _4�1 Commercial y Other ` <br /> i Number of 1i'ving units: I Number of bedrooms ` Lot size Water tableRdepth <br /> F AWL—, <br /> � � /t <br /> Character of soil ��fype <br /> hofCaacity 1 No. Compartments <br /> SEPTIC TANK /Mfg ; , ' K ' -* Method of DisposaCitPKG. TREATMENT PLT. TYPe1Mf9 Foundation` c . Property Line <br /> SEWAGE SYSTEM Di'stance,,o nearest:. Well i <br /> DESTRUCTION Cl_ 4 <br /> F ,, fnt$1-41 ength/size <br /> ;Nb: &fLength�of lines I © : y r; <br /> LEACHING LINE <br /> t Foundat hon} ���� Oroperty Line <br /> FILTER BED i Distance topnearest: Well .. <br /> 1 Nu-be�rr.,. ' 1 <br /> SEEPAGE PITS [, 'Depth:,- Size p Line <br /> Foundation __ Property <br /> _ SUMPS /�aL� �� Qistance to nearest'�ei 1 <br /> DISPOSAL PONDS ❑ R. e1}`l <br /> i <br /> 1 hereby certify that i have prepared this ap'plicatinnyand that the work will be done,in accordance with" San Joaquin county <br /> ordinances, state laws, and riles"and%ie ulationstof't•he San Jo Local Hcerti ealth Disto�cP. <br /> Home owner or licensed agent's signature Cerson1en the <br /> chfmannernas to become subjectntG,:woekman� compensaance f the <br /> California. <br /> permit is issued, I shall not employ any p g: , <br /> ` 1 Contractor's hiring or sub contracting signature certifies the followin ,'I certify that in,.the performance of the work for which <br /> this permit is issued, I shall employ persons so bjee to t'vorkman's compensation laws o Califor. ia." <br /> The applicant must cal fob al equir d inspections.. Complete drawin on reverse side. <br /> Date: <br /> 4 Signed X <br /> 1 bI�T OR ARTMENT USE ONLY Area s� I ❑48tk 466-6781 <br /> } Accepted y Lodi <br /> 6.9-3671 <br /> Application p j s 1Ty <br /> 'y.. Additional Comments: Date t D Manteca 82 7104 <br /> + t <br /> o i Pit or Grout Inspection by L Tracy 835-6385: <br /> FY Date ''D <br /> Final Inspection by t <br /> Applicant - Return all copies to: Environmental ea th Permit/Services 1601 E. Hazelton Rve., P.O. Box 2009, Stk.,{{ CA 95201 <br /> RECE11 ED 8Y OATS PERMIT NO.. t <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED .� <br /> i, <br /> INFO + <br /> 10/82 500 <br /> izi <br /> '2, LH'�3-24 REV. 10/82 <br /> },,. 14-26 A - <br />