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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HE;:LTH OISTR1CT <br /> 1501 E.CRAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone"(209} 466-6781 DATE ISSUED <br /> PERMIT ERPIRES I.YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> k hrein <br /> Application is hereblcad?onoishmadeninocompliaaceJaquin lwHealth D <br /> thSanJoaquin County Ordinance constructe'rmit to and/or install <br /> r <br /> 0 dinanceNo. 549forsewageorNo. 1862for.well/pump <br /> described. This app , <br /> and the Rules and Regulations of she San Joaquin Local Health District. - <br /> ob Address -h^�q� �ue�LGE �E. Subdivision Name <br /> JPhone V <br /> Address E <br /> I Owner's Name uiA phone -3 <br /> ` Contractor's Name FGO yl] WA _License No. <br /> TYPE OF WELL/PUOWORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION <br /> PUMP INSTALLATION (� SYSTEM REPAIR I OTHER U <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO.NEAREST:_SEPTIC .TANK 2 , � — _ Tom-—•-------T--, ---T--T _`. <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Di-a, of Well Excavation <br /> U Domestic/Private Gravel Pack L]Tracy Dia. of Well Casing <br /> i <br /> l � Public [j Other El Delta Type of Casing <br /> { V Irrigation 1 Approx. Eastern Specifications <br /> +' F_�Cathodic Protection <br /> Depth Depth of Grout Seal <br /> 1 ❑Geophysical Type of Grout <br /> !! ❑Other Surface Seal Installed by <br /> Repair Work Done Q Type of Pump H.P. <br /> State Work Done 111 <br /> Well Destruction U Well Diameter F Sealing Material (top 50') — (f1 <br /> Depth Filler Material (Below 50') <br /> TYPE 11,SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank.or seepage pit permitted if public sewer is <br /> I �DC1Nl�EAT.available within 200 feet.) <br /> installation will serve: Residence _ Commercial Other <br /> d <br /> Number of bedrooms Lot size <br /> � Number of living units: Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments Ib <br /> SEPTIC TANK F-1 Type/Mfg Capacity <br /> Capacity Method of Disposal <br /> PKG, TREATMENT PLT. ❑ Type/Mfg Property Line <br /> SEWAGE SYSTEM Distance to nearest: —Welly--«r�Foundationw_,�.__ y <br /> DESTRUCTION <br /> Total length/size <br /> LEACHING LINE U No. &i Length of lines r <br /> FILTER BED Distance to nearest: Well <br /> Foundation. Property Line`i, �. <br /> Dept Size Number <br /> SEEPAGE PITS ❑ De p , Property Line <br /> Distance to nearest: Well Foundation P y <br /> SUMPS U f . <br /> DISPOSAL PONDSin'a❑ "�-' t <br /> I hereby certify that I have prepared thisregulation <br /> thenSanhJoaquinwLocalork �Heall lthdDistricton4ccordance with San Joaquin county <br /> or which this <br /> ordinances, state laws, and ru , that <br /> Home owner or licensed agent'sisignature certifies thesucfollowing:manner as to became subjectntohwopkman�compensatilonwlaws ork fof California." <br /> son inpermit is issued, I shall not employ any p <br /> Contractor's hiring or sub-contracting certifies the <br /> of the work for which <br /> this permit is issued, I shall employ P <br /> The applicant must call for all required ins p .tions. Complete drawing on reverse side. Date: <br /> Signed X Title: -� <br /> 11 FOR D RTMENT USE 0 Y Are a�T-- (� 5tk 466-6781 <br /> Application Accepted by % 'Q` Lodi 369-3621 <br /> Additional Comments: Date Manteca 823-1104 <br /> Pit or Grout Inspecti _ Tracy 835-6385 - <br /> Final Inspection h -Date• L <br /> Ito:. Enviro tal alth Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all c i <br /> IRECEIVED BY DATE PERMIT N0, <br /> FEE BASE AMOU �UE AMOUNT REMITTE➢ <br /> ' INFO �h �S S to`7Io <br /> i <br /> i - 10/82 500 <br /> EH 13--24 REV. 10/82 <br /> :...-14.-26 <br />