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APPLICATION FDR PERMITD VSAN JOAQU'IN LOCAL HEALTH DISTRICT cral <br /> i <br /> 1601 E. NAZELTON AVE., STOCKTQN, CA IT N0. <br /> Telephone (209) 466-6781 DATE ISSUED <br /> k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 1 4 1987.. <br /> iii (Complete in Triplicate) F.WROMENTAL HEALTH <br /> P �0.k�'44I��, �11-the work herein <br /> Application is hereby made to the San Joaquin Local Health`District fora ermit' to <br /> described. This application is made in compliance with San Joaquin County Ordinanc far sewage or No. 1862 for well/pump <br /> Viand the,Rules and Regulations of the San Joaquin Local Health District. <br /> Job'Address ���ai'on NameS+u/• �^ <br /> Address .�• /t/Phone <br /> Owner's Name Phone <br /> F con'tractor's Name License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL ^� s WELL REPLACEMENT. �_� DESTRUCTION <br /> OTHER...._ —.- <br /> PUMP INSTALLATION _E _�SYSTEM REPRIR'; - �..._,,,_-,._....�- U <br /> fSEWER LINES DISPOSAL FLD. PROP. LINE <br /> STA <br /> DINCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� W <br /> } I Dia. of Well Excavation J <br /> industrial U Open Bottom Manteca u <br /> Domestic/Private �GravelPack: >0•Tracy <br /> Public Qther `Delta <br /> [� Type of Casing <br /> s V Irrigation Approx. Eastern Specifications _- <br /> i t�Cathodic Protection Depth <br /> Depth of Grout <br /> k � <br /> +Geophysical Type of Gr ut >r_ <br /> YU Other Surface 5 1 Installed by <br /> Repair Work Done ❑ Type of Pump state Work <br /> .Well Destruction U Well Diameter Sealing Material (top. 50') y <br /> i Filler Material {Below 50') <br /> Depth -'. <br /> k P ` _ <br /> f ' sewr <br /> TYPE OF SEPTIC WORK: 'NEW INSTALLATION'-EI REPRIR/ADDITION J (No ssepticc t�,ank or�seepage'piavaelableewithin u200cfeeYe) is, <br /> Installation will.serve:- M Residence _ Commercial �= Other,. <br /> `;*dNumber of living units: `` Number of bedrooms v Lot size <br /> ' Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK Type/Mfg 1 Capacity No. Compartments <br /> PKG, TREATMENT PLT. F-1 Type/Mfg <br /> { Capacity. Method of Disposal <br /> Foundation Property Line <br /> .:SEWAGE SYSTEM Distance to nearest: Well 1 <br /> DESTRUCTION <br /> } LEACHING LINE IJ No. & Length of lines z Total length/size <br /> Foundation <br /> SEEPAGE <br /> Property Line <br /> FILTER BED Distance to nearest: .,Well <br /> ' _SSze""""..'.�°".�'."""�-., Number <br /> SEEPAGE PITS F-1Depth <br /> { Distance to nearest: Well Foundation Property Line <br /> i SUMPS L<� ,p <br /> .: -DISPOsAL PONDS <br /> I hereby certify that I have prepared this application and that 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 /> ignature certifies the following:Home owner or licensed agent's sllowing: "I certify that in the performance of the work for which this <br /> as to <br /> beco <br /> ubject <br /> nt <br /> Contractor�sshiring ora subncontractingnsignaturelcertifiesnthe following: "I certifytr <br /> ot employpersonsuch <br /> thatinacompensation w <br /> the performance ofthefworkCalifornermit is which <br /> this permit is,issued, I hall employ, persons subject to workman's compensation laws of California." µ .. <br /> The applicant st 11 or al e aired inspections. Complete dra g.on versesi pate:~ <br /> ' Signed X Title <br /> DEPARTMENT USE ONLY Stk 466-6781 <br /> Application Accepted by Rrea _� __� <br /> La di ' ' 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> E 'it;ar Grout Inspection by Date �4. <br /> y 835-6385 <br /> Final. lnspection'by <br /> Date Trac <br /> - :. Environmental;;Health Permit/,Services 1661 E. Hazelton Ave.;?P:O:'Box-2009;St k`.,,.CA 95201 <br /> Applicant Return:all copies to <br /> FEE BASE` AMOUNT DUE ...AMOUNT REMITTED RECEIVED 8Y <br /> DATE PERMIT NO. . <br /> INFO O �. <br /> ! 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />