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APPLICATION FOR PERMIT <br /> SAN JOAQLiN LOCAL Ht--.LTH DISTRICT <br /> .1601 E. HAZELT.ON AVE.., "STOCKTON, CA PERMIT NO. Y13 � <br /> Telephone (209) ,466678]„ <br /> ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> F . '(Comple`te,in Triplicate) <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 i-n:compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 fo'r 'well/Pump <br /> and the Rules and Regulations of the.San Joaouin Local Health District, <br /> Job Address io W C P ^f jrtJ&bdivi-sicn,Name <br /> Owner's Name TffO 41 �W Address Phone-q -21034$ <br /> Contractor's Name License No: Phone <br /> TYPE OF WELL/PUMP WORK: :NEWiWELL WEL'L-RFPLACEMENT' F�] 4STRUCTION U 04 <br /> PUMP INSTAiLLATION ❑ SYSTEM'REPAIR L7 OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK ! SEWER. LINES "'DISPOSAL FLO. PROP. L%INE � <br /> FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> !� <br /> Industrial ,� .0 Open.�Bottom Manteca Dia, 6f Well Excavation ^ <br /> L_I Domestic/Private ' }� Gravel Pack Tracy Dia. Of Well Casing ,� l <br /> PublicF-1 Other E Delta <br /> Type of Casing <br /> Irrigation Approx. ; Eastern T- <br /> Cathodic ProtectionSpecifications <br /> depth � p � <br /> Geophysical I Depth of Grout Seal1­1 r } <br /> U Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done �J Type of Pump H.P, ` State 4dork Done <br /> Well Destruction U Well Diameteri Sealing Material (top 50') <br /> y <br /> Depth Filler'Material (Below'501 � fl <br /> rTYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION * (No septic tank or seepage pit permitted if public sewer is <br /> available within 20C feet.) f <br /> Installation willserve: Residence Commercial Other + �} <br /> Number of living units: Number of bedrooms Lot size t <br /> Character of soil to a depth of 3�feet: _ Water.table depth <br /> + SEPTIC TANK ( Type/Mfg Capacity No. Compartments " i <br /> } PKC_ TREATMENT P3 F, '.µType mfg Capacity Method of Disposal j <br /> YSTEM ,r. ' <br /> f SE "DESTRUCTI ` D'istance nearest: Well D5� Foundation Property Line ' <br /> DESTRUCTION ❑ <br /> e—LEACHIN& LINE u No. & Length of"lines Total length/siz �T SV <br /> FI`LsT6R BED �:; Distance o nearest: d ell Foundation Property Line <br /> ' SEEPAGCPITS Cj `, Depth I Size." Number <br /> SUMPS Distance to nearest; Well _11 Foundation Property Line f Cd• iec)Ap <br /> DISPOSAL PONDS'; �� s <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county fF <br /> ordinances,' state laws, and rules and regulations of the San Joaquin Local Health District. , i <br /> Home owner or.]icensed agent's signature certifies the following: "I certify that in the performance of.the work for which this <br /> permit is issued, I shallnot employ any person in such manner as to.become subject to workmant compensation laws Of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: I:ceetify 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 applicant. trust U11 4for all required inspections. Complete drawing on reverse side. <br /> Signed X :J,,,.r„tr— Title: Date_ 4", Z2-?J <br /> % M NT ONLY <br /> Application Rccepted 64f <br /> Area I Stk 466-6781Additional Comments: ��: ":� � Lodi 369-3621 <br /> Pit or Grout Inspection by :'-Date � � 1 � Manteca 823-7104 fes- r'.- �6,yr. <br /> Final In pection by _� Date' ,�ft i/ Tracy 835-6385 M0 Ydc/- @us, <br /> � L7 I <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 L. Hazelton Ave., P.O. .Box 2009, Stk., CA 95201 <br /> FEE BRSE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO.. 0�� p Gvir <br /> INFOj . . ..+.- q <br /> � <br /> �':1,,.,� - �_ u N-'Gw+�s r• i <br /> LH 13-24 REV*f10/82 +.� ..�. L/ q 10/82 <br /> 14-26 , f <br /> �v <br /> ti•• 'a �+ .� ��� f �"-b yt.• IF ; <br /> �- ai, LV 6f 1 <br />