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r APPLICATION FOR PERMIT <br /> SAN JOAQLIN LOCAL HEALTH DISTRICT PERMIT NO.�—T9- <br /> (Y <br /> 1601 E. hAZELTON AVE., STOCKTON, CA F <br /> Telephone (209) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES 1.YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made toits hem <br /> Saninocompliancel,HealSanDJoaqucn County p0rdinanoecNo5t549tfordsewagesorlNoth1862rforewell/pump <br /> described. This applicatio <br /> and the Rules and Regulations of the San Joaquin.Local Health District. <br /> Subdivision Name <br /> Job Address 8966 Hilarv Lane Phone YrS-3451 <br /> Owner's Name Mr. Daile Address 8966 Hilar Lane M r h <br /> Phone <br /> Contractor's Name Ualle Mechanical Indicense No. 333319 <br /> NE4! WELL WELL REPLACEMENT [j DESTRUCTION U <br /> TYPE OF WELL/PUMP WORK: ❑ OTHER U <br /> PUMP INSTALLATION SYSTEM REPAIR wDISPOSAL TLD. <br /> PROP. LINE .. <br /> SEWER LINES <br /> DISTANCE'TO NEAREST: SEPTIC TANK .,OTHER WELL PITS/SUMPs <br /> FOUNDATION AGRICUlr7URE WELL <br />� � � CONSTRUCTION sPECIFICAT101��"�- <br /> 3NTENDED USE TYPE OF WELL PROBLEM AREA Dia. of Well Excavation - s <br /> Manteca y <br /> Industrial U Open Bottom- ._. - <br /> 3 +'-• -- u <br /> fa. of Well Casing <br /> U Domesticl.Private ; "�Gravel Pack Tracy <br /> •, <br /> Public A x Other rEJ.Oelti 3r Type of Casing _ <br /> U Irrigation Appro�' ❑ Easters' ' specifications <br /> ,. ' • +Cathodic Protection . Depth Depth of Grout Seal <br /> Geophysical. ' .. __ Type of Grout <br /> 'i surface Seal Installed by <br /> U Other <br /> Type of PUMPh.P. State Work Done <br /> Repair Werk Done - <br /> 1 WSealing Material..(top 50`) W <br /> Well Destruction U' Well Diameter <br /> Depth's Filler Material (Below 50') µ <br /> _ - <br /> (No -septic tank or seepage pit permitted if public sewer is <br /> REPAIR/ADDITION TYPE OF SEPTIC WORK: NEW INSTALLATION U available within 200 feet.) <br /> l <br /> Installation will serve: Residence AX Commercial i Other Lot size <br /> Number of living units: 1 Number of bedrooms 4 Water;aable,tlepth <br /> Character of soil�'to?a depth of 3 feet: Capacity �_- No. Compartments <br /> T.. Ty Pe/Mf9 <br /> SEPTIC-TANK' �" LI Capacity Method of Disposal <br /> PKG. TREATMENT'PL.T. Type/MfgFoundation Property Line <br /> SEWAGE SYSTEM f7 Distance to nearest: Well <br /> DESTRUCTION 40 Total length/size 40 feet - 4" di <br /> LEACHING LINE ] No. & Length of lines 1 feet Property Line <br /> FILTER BED <br /> Distance to nearest: Well Foundation_ <br /> 24 f t Size 48" dia. Number 1 _ <br /> ( SEEPAGE PITS Depth � Foundation Property Line <br /> Distance to nearest: Well 4 �:^ <br /> SUMPS I�I _._ . s _ - 1 • - <br /> �` _F ' <br /> DISPOSAL~PONDS - <br /> + I hereby certify that I.have prepared this Hatlonsof then5an ]oaquhat inwLocalork ,Heall lthdDistrice in tccordance with San Joaquin county \ <br /> ordinances, state laws, and,r'Ules and•regu <br /> ch-manner, as to become subject to workman compensation laws <br /> lawsof ofwCalifornwhich <br /> M Nome owner or licensed agent`s signature certifies She following: I certify that in the Performance of the work for which thi s <br /> permit is issued, 1 shall t employ any person ink <br /> Contractor's hiring or sub contracting signature certifies the following: "I certify that in the per <br /> ' this perm' is ssued, I all employ persons subject to workman's compensation laws of California." <br /> The app cant st ca or req red inspections. Complete drawing on reverse side. pate: 8/0 b/64 <br /> Title: Estimator <br /> Signed X . <br /> FOR 8N31ONLY Stk - -466=6781­-- <br /> Area <br /> 466=67$1 •.----Area <br /> - Application Accepted b�J L[�� agm 4.1 Lodi 369-3621 <br /> Additional Comments: P Date Manteca 823-7104 <br /> Pit or Grout Inspection by Date L Tracy 835-6385 <br /> 1 <br /> Ik Final Inspection by <br /> to: Environmental Health Permit/Services 1601 F. HazeltonAve., P.O. Box 2009, Stk., CA <br /> Applicant - Return all copies 952 <br /> AMOUNT RENfTTFD- RECEIVED BY <br /> DATE PERMIT NO. <br /> FE10 � <br /> SE AMOUNT DUE <br /> INC <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />