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r i <br />APPLICATION FOR PEni''1:T <br />SRN JOAQLIN LOCAL HEALTH.DISTRICT 1'y <br />i <br />1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br />y Telephone (209) 465-6781 DATE ISSUED /7- y� y <br />IPERMIT EXPIRES 1 YEARFROMDATE ISSUED <br />(Complete in Triplicate) <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 Regulations of th.e. San J qui �Lo�cal /H�e►allth.0istrict. <br />Job Address / Q 3 p 2 L..* IPU � - Subdivision Name g, n�S <br />Address .S�n�7r Phone .[ <br />Owner's Name _N 2 I'f0 it MC'S Phone .Z.� <br />Contractor's Name CA il Co 6' License No. y 1�i3 <br />a.i <br />TYPE -OF WELL/PUMP WORK: NEW WELL D WELL REPLACEMENT ] DESTRUCTION ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR 17OTHER L} <br />SEWER LINES DISPOSAL FLD. PROP. LINE <br />DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br />FOUNDATION 1 AGRICULTURE WELL <br />_INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation <br />I� Industrial LJ OP ❑en Bottom Manteca 1f ° . y <br />Dia. of Well Casing <br />Domestic/Private ❑ Gravel Pack [ Tracy <br />❑ Public ❑ Other Delta :Type of Casitng r , <br />Irrigation <br />Approx. Eastern tions t <br />❑ Specifica,- <br />Depth Depth of Grout Seale <br />Cathodic Protection � <br />Geophysical Type of Grout <br />Other Surface Seal, Installed by <br />❑ <br />r .� State Work Done � <br />Repair Work Done [:]Type of Pump' h.P', <br />Wel l_L)i:ameter Y Seal ng_ ate2Q.4l <br />.�.Wei_l_Des.t.ruc.tion.U._.,, ---•- -(to.p <br />j <br />Depth'+--JIFiller Material (Below 50` ) <br />�. � f <br />TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION I (No septic tank. seepage piavaila_bleewithin d if u206 feet-) �s <br />k i <br />�... <br />installation will serve: Residence Commercial Other <br />e f - Lot size E^ •""� ; <br />Number of living units: Number of bedrooms <br />., ?:a 1 Water.table depth <br />Character of soil to a depth of13 feet:Fu -� <br />Gapacity ° No;Com.partments <br />SEPTIC TANK Type/Mfg Method of-0isposaI <br />:Capacity '2�-- <br />PKG. TREATMENTC1.LT. C Type/Mfg ° <br />SEWAGE SYSTEM -k distance to nearest:- Well <br />Foundation Property Line,. <br />DESTRUCTION' `I 4 ° <br />+h/size r <br />LEACHING LINE <br />FILTER BED <br />No. <br />' <br />U & 'Length;af lines TotalllF eng <br />nistance to nearest: Well 1p�f Foundation 3 GIProperty Line <br />j t Size Number <br />SEEPAGE PITS �j Depth Property Line <br />SUMPS <br />Distance to nearest: Well Foundation <br />Distance <br />DISPOSAL PONDS ❑ <br />x <br />r <br />the work will be done in accordance with <br />I hereby certify that I have prepared this application and than Joaquin county <br />ordinances, state lAs, and rules and regulations of the'S6ri,.Joaquin Local Health District.,f the work <br />e performance o, <br />Home owner or licensed agent's signature certifies <br />such�mannernas to becomeysubjectthat ntohworrWan§ compensation lawsfOf California." <br />permit is issued, I shall not employ any 9 g. y p <br />Contractor's hiring or sub-contractin srsonsure certifies tre f011Oompensationrlaws ofaCalifornia.�fo�mWa�nce of t work for which <br />this permit is issued, I shall employ ! <br />The applica t call for all requi d inspections. Complete drawingonon revise side" D�{e, <br />Title: owe <br />vel" <br />X �=►"'� � � <br />DEP M USE Y / ❑ Stk 466-6781 <br />rea —f,� <br />Application Accepted by Lodi 369-3621 <br />Additional Comments: Manteca 823-7104 <br />Pit Or Grout inspection by. Date <br />Date y ❑ Tracy �-B3_5-6385 <br />Final Inspection by ^� <br />Applicant - Return alh copies to:. Environmental Health Permit/Services 1601 E. Ha elton Ave„ P.O. Box 2009,�Stk-', CA 95201 <br />FEE I BASE AMOUNT. DUE <br />INFO ` , <br />EH 13-24 REV. 10/82 <br />14-26 <br />AMOUNT REMITTED RECEIVED BY <br />— <br />OATE I PERMIT NO. <br />10/62 500 <br />.'1 <br />