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7 <br /> &A <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA f2; 4 1984 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> L, ,,� C,T <br /> (Complete in Triplicate) HLALTH - . <br /> Application is hereby made tothb San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City NLot Size L-- PM <br /> -7 <br /> Owner's Name Jnrare i,I-C)L Addressbc))< 7-4 Phone <br /> Contractor's Name S. r'%JNjPkicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 71 DESTRUCTION El'# <br /> PUMP INSTALLATION 71 SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE-TO NEAREST: SEPTIC.TANK<10.0 +—SEWER LINES--z DISPOSA[:--'FLD— --PFIOP.-LINE---" . <br /> FOUNDATION AGRICULTURE WELL OTHER WELL--��PITS/SUMPS,— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !f <br /> — A-21= <br /> A Excavation Dia. of Well Casing <br /> 11 Industrial [7 Open Bottom 0 Manteca Dia. of Well Excav <br /> Domestic/Private 'Gravel Pack F] Tracy Type of Casing Specifications <br /> 11 Public 0 Other 0 Delta Depth of Grout Seal Type of drout&aAna 0�c 41 <br /> EI irrigation ---Approx. Depth 0 Eastern Surface Seal Installed by)N erN n d f=-, <br /> Repair Work Done D Type of Pump H.P. State Work Done <br /> f. Well Destructi8n ID Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') _.permitte, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system d if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units:— Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth 2 <br /> SEPTIC TANK 0 Type/Mfg Capacity_ No. Compartments 7- <br /> PKG. TREATMENT PLT. El Method of Disposal <br /> Distance to nearest; Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation— Property Line <br /> SEEPAGE PITS 0 Depth Size Number <br /> —SUMRS .0., 'Distance-to-nearest:—Well Foundation�,I--- Property-Line-==�::�---�� <br /> DISPOSAL PONDS F-I '?:. - I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 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 permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title. Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> —ex Final Inspection by gc,�, Ote <br /> Pit or Grout Inspection bya=t! <br /> Additional Comments: n., <br /> U Stk 466-6781 E Lodi 369-3821 L) Manteca 823-7104 11 tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009r Stk., CA 95201 <br /> I _1 K# DATE PERMIT`NO. <br /> FEE �C,�k RECEIVED BY <br /> AMOUNT DUE AMOUNT REMITTED INFO <br /> +EH 13-24(RW.10/83) <br /> Ell W26 <br />