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APPLICATION FOR PERMIT <br /> SAN JOA UIN LOCAL HEALTH DISTRICT <br /> AUG 24138 1661 E. � <br /> HAZELTON AVE., 5T6CKTON, CA PERMIT N0. r�� '•-. <br /> Telephone (209) 466-6781 DATE ISSUED✓ <br /> rg J ''A QMW .MAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> HATH DIST !GT (Complete in Triplicate) <br /> Application is hereby made to the San`Joaquin Local Health District for a permit to construct and/or install the workherein <br /> a <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 far sewage or No. 1862 far well/pump <br /> and the Rules and Regulations of the15an Joaquin Local Health District, <br /> Job Address eT Subdivision Name <br /> Owner's Name <br /> Address •1 'T Phone , <br /> License No. _ Phone <br /> Contractor's Name a � <br /> TYPE OF WELL/PUMP WORK: NEW WELL F7 WELL REPLACEMENT DESTRUCTION U OZS <br /> PUMP INSTAL�ION SYSTEM REPAIR OTHER U <br /> Q15POSAL'FLD. PROP. CINE'`; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER 1d ELL PITS/SUMPS Q]� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> IJ Industrial [f Open Bottom ❑Manteca Dia, of Well Excavation <br /> Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing <br /> I] Public F-1 Other+ 0 Delta Type of Casing <br /> Ljlrrigation Approx. ❑ Eastern Specifications <br /> Cathodic Protection Pepth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout ' <br /> Other Surface Seal Installed by <br /> Repair Work Done Type of Pump '. H.P. v"`a/ State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501 <br /> Depths Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION F1 REPAIR/ADDITION ❑ (No septic tank or seepage piavailableewithinubl200cfeet sewer is <br />' Installation will serve: Residence Commercial _ Other J <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: - <br /> Water table depth <br /> _'i— .+ :. r -^^ 'Capacity ` . -No_Compartments._.. -. � ___..-�._ <br />;•""`� SEPTIC' AZI" ,Type/Mfg <br /> Capacity Method of Disposal <br /> PKG. TREATMENT PLT. U Type/Mfgl , <br /> SEWAGE SYSTEM Distance,to nearest: Foundation Property Line <br /> Well <br /> DESTRUCTION + <br /> LEACHING LINE {� No. & Length of lines Total length/size <br /> FILTER BED ❑. <br /> Distance�to nearest: Well Foundation Proferty Line <br /> SEEPAGE PITS Depth Size Number I <br /> SUMPS L I <br /> Distance to nearest: Well Foundation Property Line <br /> -DISPOSAL PONDS Cl y <br /> r 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 rulesland 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 /> not employ any person in such manner as to become subject to workmanK compensation laws of C <br /> permit is issued, i shall na3ifornia." <br /> Contractor's hiring or'sshall contracting signature certifies the following: "I certify that in the performance of the work for which <br /> bject to workman's compensation laws of California." <br /> this permit is issued, I shall employ persons su <br /> The applicant s all for re pec icuy6., Com Tete on re r side. ' Date:w Signed X Z/�.{�'►// t e: <br /> 0 DEP% T N SE ONLY 7� '� _ Stk 466-6781 <br /> Application Accepted by Area <br /> (] Lodi 369-3621 <br /> Additional Comments: <br /> Pit or Grout Inspection by <br /> Date - l� Manteca 823-7104 - <br /> � Lm." �,.�� Date-140— fi3 �:�L.Tracy 835-6385. <br /> Final Inspection by <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5t k., C% 95261 <br /> FEED BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> GATE ��PERMITNO. - <br /> pa,�St-:833 -3 <br /> 10/82 500 <br /> EH 13-24 REV. 16/82 -� <br /> 14-26 ? <br />