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h <br /> APPLICATION FOR PERM:T <br /> T SAN JOAQUi„' LOCA? HEuLIH DISTRICT <br /> Fj 1501 E. H47ELTON AVL., STOCKTON, CA PERMIT NO. �yr-��Q O <br /> F 7� � � Telephone (209) 466-6781 <br /> -I DATE ISSUED <br /> PERMIT EXPIRES i YEAR FROM DATE I55UFD <br /> (Complete in Triplicate) <br /> Application is hereby made to thelSan Joaquin Local Health District for a'permit to construct and/or 'install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulationsthe San Joaquin Local Health District, <br /> Job Address-is' f ASubdivision Name <br /> Owner's NamePhone <br /> Address <br /> Contractor's Name L!� License No. Z� y _ Phone <br /> TYPE OF WELL/PUMP WORK: 'NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR -OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FL_O, PROP. LINE <br /> FOUNDATION 4 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r " <br /> INTENDED USE TYPE.DF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of WellExcavation <br /> U Domestic/Private Gra el Pack ❑ Tracy J Di�a.�of Well Casing: �� <br /> Public �j Other Delta:_._ '"'""" -Type of-Casing <br /> Li Irrigation -4-pprox- '--0-EasterSpecifications <br /> "` <br /> Depth Cathodic Protection p <br /> ' <br /> LJ Geophysical ` •Depth of Grout Seal <br /> 'r � � � F <br /> U Other t Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump # H.P. x" State Work Done / <br /> Well Destruction U Well-Diameter ""`+^­ `-Sealing Materiala(top 50') <br /> Depth . Filler Material (Below 50')' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> — available within 20D feet.) <br /> Installation will serve: Residence Commercial r/ other <br /> Lr <br /> Number of living units: Number of bedrooms Lot size ����, <br /> Character of soil to a depth 013 feet: 41j Pte,,... Water table depth �-C7 <br /> SEPTIC TANK Type/Mfg. c Capacity 1 7_0 e w n-V- No. Compartments (� <br /> Type/Mfg Capacity o �r 1 �- <br /> SEWAGE SYSTEM 'Distance--to nearest: Well Foundation1 <br /> t[3 Property Line <br /> DESTRUCTION I <br /> LEACHING LINE No. & Length of lines _r —' 4 �' Total length/size q-0 "`1(�� <br /> FILTER BED Distance to nearest: Well Foundation ! property Line' <br /> SEEPAGE PITS Depth t '2-4— Size �� J Number 1 <br /> II SUMPS Distance to nearest: Well Foundation 10 Property Line $��= <br /> DISPOSAL PONDS <br /> r <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 in such manner as to become subject to workman5 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 workman's compensation laws of California." <br /> The applica ti must call f all required inspections. Complete drawing or reverse side. rr <br /> Signed }( � _ Title: Date: ? 7 <br /> �FO�-�p�PARTM NT USE ONLY <br /> Application Accepted by /y // �/ Area _ _r µ Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date - 7�Jr� Manteca 823-7104 <br /> I Final Inspection by Date �Gi Tracy $35-6385 <br /> Applicant - Return all copies to: _ Environmental He lth Permit/services 1601 E. Hazelton)h ,!., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO. <br /> fr LA '' #•. tea...:. w+�,,... - aee-..s.-.�-+mne�r - 7 7" 'h ��.�....�. <br /> EH 13-24 REV. 10/82 "` 10/82 500 <br /> 14-26 <br /> f <br />