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APPLICATION FOR PERMIT <br /> =r,'•..' t SAN JOAQUiN LOCAL HEALTH ,DISTRICT <br /> 1601 F. HA7ELTON AVE, STOCKTON, CA 'T <br /> # Telephone (209) 466-6781 PERMIT NO. <br /> 4 f <br /> s .{ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> DATE ISSUED 1 <br /> �kp <br /> (Complete in Triplicate) <br /> AAPlication is hereby made to the•5an 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 RuTes an ati0 of.the San Joaquin Local- Health District,. <br /> ,lob Address ( S r <br /> Owner's Name Subdivision arae <br /> + Contractor's Name C i ` t <br /> Address S <br /> License No. Phone <br /> ` Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL <br /> { <br /> L REPLACEMENT DESTRUCTION <br /> PUMP-IN5TAL•L-ATI .5•YSTEM-REPAI•R�-•--.•E.. ER- 1D� <br /> DISTANCE TO NEAREST: SEPTIC DANK �� Ll <br /> SEWER LINES DISPOSAL FLD. C <br /> FOUNDATION AGRICULTURE WELL PROP. LINE t r <br /> 07HER WELL PITS/SUMPS f J <br /> j <br /> INTENDED USE TYPE <br /> E OF WELL PROBLEM <br /> 410 Indysttial CONSTRUCTION SPECIFICRTIONS <br /> LL's LJ Ope tvm anteca Dia, of Well Excavation e ri <br /> omesticlPrivate raves Pack <br /> ❑ Public ❑ Tracy Dia. of Well Casing <br /> Irrigation <br /> Other EJ Delta <br /> L-iA Type of Casing <br /> FJ- Cathodic Protection Deprox ❑ Eastern <br /> SpecificationsLJ ` <br /> Geophysical Depth of Grout Seale -. _ <br /> J 1 Other a Type of Grout C <br /> S4 ! <br /> RSurface Seal Ins alTed by <br /> Repair Work Done <br /> Type of Pump 1� H P State Work Done , I <br /> Well DesSeaISO <br /> Destruction U Well Diameter ! ! <br /> f Depth ling Material' -----/—(top 50') <br /> Filler Material (Below 50') — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> U REPAIR/ADDITION vU "( o septic tank or seepage pitpermitted if public sewer is <br /> Commercial Other � O f <br /> Installation will serve: Residence i <br /> _ available within 2D0 feet.) <br /> Number of living units: Number of bedrooms " <br /> Lot size <br /> Character of soil to a depth of 3 feet: ^ 3 <br /> SEPTIC TANK Type/Mfg ; Water table depth <br /> PKG. TREATMENT PLT ❑., Type/Mfg Capacity No, Compartments <br /> SEWAGE SYSTEM f� Capacity Method of Disposal <br /> DESTRUCTION r�1 Distance to nearest: Well Foundation ' <br /> Property Line <br /> LEACHING LINE Cl No. & Length of lines <br /> FILTER BED z Total length/size , } <br /> w Distance to nearest: Well <br /> Foundation € PropertyiLine <br /> SEEPAGE PITS <br /> _Q Depth' Size <br /> SUMPS � " Number <br /> U } Distance to nearest: Well Foundation ' <br /> DISPOSAL PONDS PrapertytLine <br /> � •; -d ' <br /> I hereby certify that I have prepared this application and that the•w6rk 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 Toy any person in such manner as to become subject to workman compensation laws of California," <br /> Contractor's hiring or s -contr i Sig re certifies the following: "I certify that in the.performance of the work for which <br /> this permit is iss d, a 1 per n subject to workman`._s`oom nsation laws of California," <br /> The app lican s 11 req in ctions. Complete'UP-awon <br /> + _ t <br /> (A- ? <br /> ea .2 ju <br /> FDDE MENT USE ONLY <br /> Application Accepted by <br /> Additional. Comments: �� <br /> - z, Area --�•-- Stk 466-6781 <br /> 1. 1 .n <br /> Pit or Grout InspectionD <br /> Ay <br /> . ate � 823-- <br /> 7104"•'"""_ Lodi 369-3621 <br /> � C -,�...�" -"'""_—^— <br /> O Manteca <br /> Final Inspection by � <br /> Date r- � L Tracy 5 <br /> Applicant - Return all copies o; Environmental Health Permit/Services 1601 E, Hazelton Ave., P.D. Box 2009, 5835-638638CA 95201 <br /> LINFO <br /> BASE fAMOk� AMOUNT REMITTED <br /> RECEIVED BY DATE PERMIT N0, <br /> b =7T <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br />