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C APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �p <br /> I 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 0 a 7x <br /> Telephone (209) 466-6781 <br /> OATS ISSUED �r � <br /> 4. PERMIT EXPIRES liYEAR FROM DATE ISSUED '--7—" <br /> (Complete� in Triplicate) f <br /> Application is hereby made to theSan 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 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. , <br /> 1 <br /> Job Address <br /> SW 1WAAli ts,e �D fiP��P; Subdivision .Name � <br /> Owner's Name DEQ i Cp_ G A r_114 E P e7 Address Phone <br /> Contractor's Name1=e]VZ? K IV-4ab ^ License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ] WELL REPLAGEMENT DESTRUCTION <br /> CA <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER Q' <br /> DISTANCE TO NEAREST: SEPTIC TANK ;� SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION ,� AGRICULTURE WELL OTHER WELL PITS/SUMPS ; <br /> INTENDED USE TYPE OF WELL Industria] PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Open'Bottom 0 Manteca Dia. of Well Excavation V" <br /> 1­1Domestic/Private E]Gravel Pack 0 Tracy Dia, of Well Casing <br /> 17 Public Others Delta <br /> L_IIrrigation Approx. [� Eastern Type of Casing <br /> ❑cathodic Protection Depth Specifications <br /> 0 Geophysical E l Depth of Grout Seal 3 <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump N.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION [ (No septic tank or seepage pit permitted if public sewer is <br /> _1 <br /> Installation will serve: Residence available within 200 feet.) <br /> _� Commercial t Other <br /> Number of living units: �-_y Number of bedrooms -3 Lot size 13 1"`X 3 dp <br /> Character of soil to a depth of 3 feet: LQ Water table depth i <br /> SEPTIC TANK Type/Mfg L Capacity _��a No. Compartments <br /> PKG. TREATMENT PLT. EJ Type/Mfg E Capacity �� Method of Disposal <br /> Distance to nearest: Well 1 01D Foundation �p Property Line <br /> k , <br /> LEACHING LINE No. & Length of lines J _7.4 Total length/size -2�f0 <br /> FILTER BED EJ Distance to nearest: Well - Foundations Property Line SO <br /> SEEPAGE PITS CJ Depth ;J Size Number <br /> SUMPS, ` ❑ Distance to nearest: Well k Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application andlthat the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and 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 /> 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 certifiesRthe following: "I certify 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 must call for all requir, d inspections. Complete drawing on reverse side. <br /> Signed X F <br /> Title: Date: -,j z- <br /> FOR DEPARTMEN E ONLY /� <br /> Application Accepted by L �. Area 5tk 466-6781 <br /> Additional Comments: :J IM. ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by ! Date Manteca 823-7104 i <br /> Final Inspection by I f Date "Z_ Tracy 835-6385 <br /> Applicant - Return a17 copies to: Environmental th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE BASE AMOUNT DUE. AMOUNT REMITTED RECEIVED BY <br /> INFO DATE PERMIT N0. <br /> ' <br /> 13-24 k <br /> EH 14-26 REO. 10/82 y 10/82 500 <br /> IE <br />