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•APPL.ICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466.-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> i <br /> (Complete in Triplicate) <br /> i <br /> Application is hereby made to the San 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 Regulations of the San Joaquin Local.Health District. <br /> Job Address /3 d 5z 7,9 ! / /rJ Subdivision Name <br /> Owner's Name <br /> -PoAl C-& 6 AJ Address . /.3Z:�SfJ . �. ��/�/�i✓ G�� hone.;i? <br /> Contractor's Name r / Li ense No, Yily Agi__? Phone <br /> KJ <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION ..' SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK aZO c, 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 /> - - -tom-industrials- ­—��per�Bottom-=^-1 Manteca - *- Dia--of•Well•Excavation {}`,�'n _ <br /> ' mestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public Other Del to Type of Casing <br /> LjIrrigation 4_f" rox. Eastern Specifications <br /> ❑ <br /> Cathodic Protection Depth� Depth of Grout Se�l �� 2�. <br /> Geophysical Type of Grout 6-1 /77 <br /> ..7� J <br /> FJ other P v Surface Seal Installed by_ _ /_i1/�d_I^ l/1 <br /> Repair Work Done ❑ Type of Pump +: H.P. - . State Work Done <br /> Well Destruction U Well Diameter l Sealing Material (top 50') _ G <br /> i <br /> Depth l Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 71 REPAIR/ADDITION j L (No septic tank or seepage pit permitted if public sewer is ` <br /> A available within 200 feet.) Q <br /> Installation will serve: ' Residence Commercial _ Other f ,. <br /> Number of living units: Number of bedrooms Lot size <br /> Character of sail to a depth of 3 feet: T Water table depth <br /> SEPTIC TANK ❑ Type/Mfg! Capacity No. Compartments <br /> PKG. TREATMENT PLT. [] Type/Mfg Capacity Method�of Disposal <br /> 4E <br /> SEWAGE SYSTEM c Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION 1 <br /> F. <br /> LEACHING LINE U No. & Length of lines. Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth I Size LL Number <br /> SUMPS Distance to nearest: Well " -Foundation _ ' -,JPrQperty Line r <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 in such manner as to become subject to workmarS 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 /> t <br /> The applicant must call for all required inspections. Completedrawingon reverse side. _ c <br /> Title: C - C't-J7`?��. 4 Date..-�` o� �O / <br /> Signed X „ A <br /> F DEPARTMENT USE ONLY 11W <br /> Application Accepted by Area Stk 666781 <br /> Additional Comments: Lodi 369-3621 'Nr . <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> — <br /> Date i (� T} Tracy 835-6385 <br /> Final Inspection by <br /> Applicant - Return all copies-to: ., Environmental Health Permit/Services 1601 E. Hazelton Ave P.0. Bax 2O09, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE <br /> ��lRMIT NO.INFO ` —bS SL <br /> tN { <br /> JV - d <br /> 10/82 500 <br /> -- <br /> EH 13-24 REV. 10/82 f, • ��QS <br /> •. � <br /> . 14-26 ...- <br />