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PERMIT NO. r <br />DATE ISSUED <br />uASE FEE <br />INFO <br />Application Accepted by <br />A itlonal Comments: <br />r Grout Inspection <br />nal Inspection by <br />Applicant - Return all copies to: Environ enta <br />.USE <br />Date <br />h Permit/Services 1661 E. Hazelt <br />Stk 466-6781 <br />Lodi 369-3621 <br />0 Manteca 823-7104 <br />LJ Tracy 835-6385 <br />P.O. Box 2009, Stk., CA 95201 <br />AMOUNT ouE AMOUNT REMITTED RECEIVED BY <br />Eh 13-24 REV. 10/8; <br />14-26 <br />10/82 500 <br />••••?....• <br />APPLICATION FOR PERM:1 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HA2ELTON AVE,, STOCKTON,' CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) - <br />Applicatior is hereby rade to the San Joaquin Local Health District for a permit to construct end/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 and the Rules and RegulatipAs o' the San Joaquin Local, Health Dfstrict. <br />Job Address J./.2 /4/r ‘7541 , S ubdivision Name <br />Owner .s Name <br />'s Or , <br />Address 4W.j/412 . AgeoL7Pro Phone <br />Contractor Nacre <br /> <br />VoNe/e.- License No, 32yr2,j_4, Phone <br />CONSTRUCTION SPECIFICATTOKS <br />Dia. of Well Excavation <br />Dia.-of Well. Casing <br /> <br />LiGeophysical <br />0 Other <br />Well Destruct13i. Well Diameter! <br />Repair Work Done D Type of Pumpel <br />1„,e <br />State Work Done <br />Surface Seal Installed <br />TYPE OF SEPTIC WORK: NEW 1NSTALLAil REPAIR/ADDITION f. (No septic tank or seepage pit permitted if public sewer is <br />Property Line <br />70tal length/size 96.14 <br />3 s " Number ,=p/ <br />TYPE OF wELL/PUMP WORK: NEw;wE_L WELL REPLACEMENT 0 <br />PUMFINStALLATION12""—SYSTEM-REPATR <br />DiSTARCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER'WELL PITS/SUMPS <br />DESTRUCTION 0 <br />4, o:AER,,L771.;4._ <br />INTENDED USE <br />0 Industrial <br />Domestic/Private <br />Public <br />U Irrigation"' • • • .- <br />0 Cathodic Protection <br />' TYPE of WELL <br />0 Open Bottom n Gravel Pack <br />El Other , <br /> Approx. <br />' Depth <br />PROBLEM AREA <br />o Manteca <br /> Tracy <br />Deltao <br />Eastern <br />Type,of Casing <br />Spe!..cifications <br />Depth "Of Grater Seal <br />Type o Grout <br />by <br />Depth <br />.; <br /> Sealing Material (top SO') <br />Filler Material (Below 50') <br />SEEPAGE PITS <br />SUMPS ' <br />DISPOSAL PONDS <br />Installation will serve: Residence Commercial <br />Number of living Q <br />Character of soil <br />SLPIIC TANK <br />PKG. TREATMENT PLT. <br />SEWAGE SYSTEM <br />DESTRUCTION <br />LEACHING LINE <br />FILTER BED <br />. <br />. L j Di stance 'to nearest: Wel l Clop kr-roundat inn Property Line _.,5 /r' <br /> <br />0 Type/M4gi Capacity <br /> <br />:I <br />Distance to WelljAcoadr" Foundation <br />25' No, S Liiiqth of lines y r <br />U. Distance .to nearest: Well _Ett.4,10undation //.r-Property Line <br />Depth 0....,rEr7 Size <br />units: / <br />.1 available within 200 feet.) <br /> Number of bedro <br />to a deptn of b feet: <br />' Lot si is _221114L,A,_ /5.0 / .4' <br /> Water table table depth Fo/...r- Er' Type/P441 Capacity _Agi_014.4 No. Compartments <br />Method of Disposai <br />I hereby certify that I have prepared this application and that the work will Pe done in accordance with San Joaquin county <br />ordinances, state laws, and rules and regulations of the San Joaquin total Health District. <br />Nome owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for wtOch this <br />permit is issued, I shall not employ any person in such manner as to become subject to workmates compensation laws of California." <br />Contractor's hiring or sub-contracting signature certifies the following: "1 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 applict must call for reulred inspections. Complete drawieg on reverse side. <br />Signed X Title: Date: -P11