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APPLICATION FOR PERMIT
<br />SAN JOAQUIN LOCAL. HEALTH DISTRICT
<br />1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. .: .
<br />Telephone (209) 466-6781 r
<br />DATE ISSUED
<br />PERMIT EXPIRES I YEAR FROM DATE ISSUED r s
<br />(Complete 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 in compliance with San Joaquin County Ordinance No, 549 for sewage or No,,1862 fell/pump
<br />and the Rules and Regulations of the San Joaquin Local Health District.. / f
<br />Job Address -An
<br />ik1iCK.,P_.?J't.ai1�1�. .. Subdivision Name •�
<br />Owner's Name 11E__����$� f ._ �}- Address,R0, Jff7. 6W7.'9: � IQ&QUW3, Phone& tC-309%
<br />Contractor's Nametd License No. i"C�_�--_,� _ Phone •^—CZ
<br />TYPE OF_WELL/PUMP 'WORK: NEW WELL ] WELL REPLACEMENT [] DESTliUCT ION [j
<br />_ •�-�. lI PUMP [NSTALLATION SYSTEM REPAIR OTHER..d=j—+-»�
<br />} DISTANCE�TO NEA�E5Ttl S£PT,I�C �TANK� f 3 .3 'a'i, SEWER L`TN �+'�la �rt� 3 D:L POSAL I,R,s •. PROP. LINE
<br />s FOUNDATION ?AGRIGUZTURE WELL OTHER WELL _ _ _ _PITS/SUMPS _
<br />--- ,-.
<br />INTENDED USE
<br />TYPE OF WELL.
<br />Industrial 1
<br />Open, Bottom
<br />[1 Domestic/Private
<br />Gravel Pack
<br />17 Public !
<br />CJ Other
<br />t
<br />Irrigation
<br />Approx.
<br />Cathodic Protection
<br />Depth '
<br />Geophysical
<br />i
<br />EJ Other �
<br />"•
<br />Repair Work Done
<br />Well Destruction 1
<br />Type of Pump
<br />Well Diameter
<br />Depth _.
<br />PROBLEM AREA.
<br />Manteca ~�
<br />Tracy
<br />L_JDelta Type of Lasing s
<br />(� Eastern Specifications
<br />Depth of Groui'Seal
<br />Type of Grout`
<br />Surface Seal Installedby
<br />_
<br />H. 1). _ State Work•Done 4
<br />_ Sealing Material (top 501)
<br />Filter Material (Below 50') r' _
<br />�.CUfV57RUCTlON SPECIFICATIONS
<br />�.. _.Oia. of Well Excavation
<br />Dia. of Well Casing }
<br />TYPE OFiSEPTIC WORK: NEW INSTALLATION [ REPAIR/ADDITION? (No septic tank or seepage pit permitted if public sewer is 1
<br />j s available within 200 feet.) ,
<br />Installation will serve: Residence Commercial XOther
<br />Number of living units: Number of bedrooms Lot si%e /.,R_ Z.SJ►Q r• t
<br />i
<br />Character of
<br />`
<br />soil to
<br />e + /�,�,,,,�
<br />a depth of 3 feet: �f
<br />i
<br />_
<br />Water table depth
<br />,_,.._ P _.,,,.:.....,._..�.
<br />—
<br />SEPTIC TANK
<br />t
<br />Type/Mfg
<br />Capacity
<br />No. Compartments
<br />PKG. TREATMENT
<br />t
<br />PLT.
<br />.........
<br />Type/Mfg :
<br />Capacity'_
<br />__ Method of Disposal
<br />SEWAGE �YSTEM
<br />l
<br />_ _
<br />Distance to nearest: Well
<br />Foundation - _�
<br />_
<br />Property Line
<br />DESTRUCTION
<br />' i-1
<br />. /
<br />€ C
<br />LEACHING LINE ;� No, & Length of lines �' 1
<br />FILTER 6ED [ Distance to nearest: Well �� Fo
<br />Total length/sine •,� ,1iEi €S'
<br />tion i Property Line f a
<br />SEEPAGE4PITS `Depth ...�, Size _a� �,. Numb`erf"�'
<br />SUMPS [J Distance to nearest: Well Foundation^_� Property Line
<br />DISPOSAL PONDS 1 �
<br />r
<br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county -41
<br />ordinances,.state laws, and rules and regulations of the San Joaquin Local Health Districi'.• !
<br />Home owner or licensed agent's signature certifies the following: "I certify that in the perfoMiance of the work for which this
<br />permit is issued, I shall not employ any person in such manner as to become subject to workman§ compensation laws of California."
<br />Contractor.'s hiring or sub -contracting signature certifies the following: "I certify that in�the performance'.of the work for which y
<br />this per is sued, T shallXalpl pe sons subject to workman's compensation laws of California."The applican � t call r alr inspections. Complete drawing on reverse side,
<br />Signed % _ Title:3FZ
<br />r.
<br />. �ARTMEN FUSE ONLY
<br />Application Accepted by' ""'-Area _ S0 C'!� y678]
<br />a
<br />Additional Comments: r" €•+v ..� '� _ [� Lodi 3$b x,621 1 4� �tirr
<br />,..........`ad�ee yam. w{^-
<br />-Pit or Grout Inspection by I04
<br />"Final Inspection by"i•irdr x$35 -63A5 +,XI
<br />Applicant - Return all copies En fteonmental Health Permit. Sery ces 1601"E. Hazelton Ave:, P.O. Box 2A09; Stik"; rA "95201
<br />f
<br />".' �T. -.> ....----itEGfI•VEU-BY--- .�-DAT•C+,.:-----..-PERdI1 NO.,..^
<br />10/82 500
<br />EH 13-24. REV. 10/82
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<br />E7AMOUNT"DUE-1—_
<br />---_..——'—
<br />AMOUNT" REMIT LD
<br />—
<br />INF�J�—BX.SIE—
<br />10/82 500
<br />EH 13-24. REV. 10/82
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