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APPLICATION FOR PERMIT J <br />r P SAN JOAQUIN LOCAL HEALTH DISTRICT ( <br />PERMIT N0. 777 <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 DATE ISSUED <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) IJ <br />Application is hereby made to the San Joaquin Local Health District fora 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 Regula ion of e San Joa ui Local Health -District. <br />Job Addres L ubdivision Name <br />r � hone <br />Owner's Na Address <br />Phone� ie-;2� <br />Contractor's Name p License No. <br />TYPE OF WELL/PUMP WORK: NEWWELL [] WELL REPLACEMENT DESTRUCTION Lj <br />OTHER <br />PUMP INSTALLATION SYSTEM REPAIR LJ <br />DISP05AL FLD, PROP. LINE <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br />OTHER WELL PITS/SUMPS <br />MFOUNDATION AGRICULTURE WELL —�— <br />w f <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT30N:5PECIFICATIONS <br />Dia., of Well Excavation <br />F-1IndustrialiJ Open Bottom ❑ Manteca Dia. of Well Casing <br />E2Domestic/Private EJ Gravel Pack Tracy _ <br />Public [iOther Delta Type of Casing <br />V Irrigation Approx. Eastern Specifications, <br />Cathodic Protection <br />Depth -- Depth of Groutl Seal <br />❑ Geophysical ;Type of Grout <br />LJ Other ! Surface SealrInstalled by <br />of Pump H.P. "" ' Sealing MateState 'Work,Done <br />Repair Work Done E]Type _ <br />rial (top 5D') <br />Well Destruction ❑ Well Diameter .. , <br />Depth Filler Material (Below 50')' <br />sewer <br />it <br />TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No sept tank�or seepage pzavailableewithinu200cfeet.) is <br />Installation will serve: Residence ; Commercial Other I <br />Number of living units: —Z— Number of be ooms <br />Lot size <br />_ Water table depth 7 <br />Chars ter' of soil to a depth of 3 feet: tR , No. Compartments <br />F -1y <br />SEPTIC TANK <br />�Capaci' Type/Mfg Method of Disposal <br />PKG. TREATMENT PLT. [J Type/Mfg Capacity Property Line <br />SEWAGE SYSTEM F-1Distance to nearest: Wel fi Found d o <br />DESTRUCTION ti h <br />LEACHING LINE <br />FILTER BED' <br />Total lengt /size <br />No. & Length of lines Property Line <br />Distance to nearest: Well Foundation <br />SEEPAGE PITS Depth /� <br />SUMPS EJ Distance to nearest: Well /h 7� i <br />Foundation --/v-- Property Line _�� <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.ing: in 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 />permitis <br />issueiring,orasubn�ontractingnsignature,n' such certifies-the-followner as to ing: "I certifysubject ecometthatrinathe performance ofompensation wthefworkryfor nwhich <br />Contra <br />this permit is issued, I shall employ persons subject,�to workman's compensation laws of California." <br />. -f� ,; �. <br />The applicant mus call for I r iced in specteons. Complete drawin �on� r rse side. Date: <br />4 4-91 <br />Title: 9 1/• <br />Signed X <br />D DEPARTMENT USE ONLY Area � � Stk 46fi-6781 <br />Applica io Accepted by ""'"iiii Lodi 369-3621 <br />Additional Comments: Date E]Manteca 823-7104 <br />Pit or Grout Inspection b Date $Cj Tracy 835-6385 <br />Final Inspection by CA 95201 <br />Applicant - Return all copie to:. Enviro me tal Health Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, Stk., <br />RECEIVED BY DATE PERMIT NO. � <br />FFEE BASE AMOUNT DUE AMOUNT REMITTED 7 1 `1 <br />INFO " C 3� �K7 I <br />10/82 500 <br />EH 13-24 REV. 10/82 j <br />14-26 Ei <br />