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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 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED GATE ISSUED <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 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address Subdivision Name - <br /> Owner's Name GA R1_ Address �� �3 G , i,M5/�/�6, 7^OAj ST' Phone mey <br /> Contractor's Name PrAA2 . WL10J> License No. ��rZ.7 ,_ Phone Vk4 -.3 Q L7 <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q 9t ?WELL. REPLACEMENT DESTRUCTION F-1 W <br /> PUMP INSTALLATION"[—]— "SYSTEM REPAIROTHER � 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION f AGRICULTURE WELL 1 OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom [I Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravely{Pack w w Q,Tracy Dia y of Well Casing <br /> Public EJ Other Delta <br /> Irrigation Type of Casing <br /> Lj 9 Approx. Eastern ' <br /> F—ICathodic Protection Depth ! Specifications <br /> t Depth of Grout Seal <br /> Geophysical ✓! <br /> Type of Grout ' <br /> U Other <br /> Surface Seal Installed by <br /> r <br /> Repair Work Done Type of Pump i",H.P, State Work Done <br /> { <br /> Well Destruction LJ WelI Diameter I € 14 kSealing Material (top 50') _ k <br /> Depth 1 Filler Material (Below 50') -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> E <br /> available within 200 feet.) <br /> Installation will serve: Residence ,,+ Commercial _ Other <br /> Number of living units: .. :.Number of,bedrooms l Lot size _Aca <br /> s <br /> Character of soil to a depth of 3 feet: E Water table depth <br /> SEPTIC TANK [1 Type/Mfg &I —.x�g�,� Capacity d 7,,&47 No. Compartments 7, <br /> PKG. TREATMENT PLT. Type/Mfg i ( Capacity+ Method of Disposal <br /> SEWAGE SYSTEM ° Distance to nears t:.,Well /V Foundation /�d r� , Property Line g <br /> DESTRUCTION ,,Q ! "*.' <br /> LEACHING LINE No. & Length of lines f :71-- A,, Notal length/siie . <br /> FILTER BED ❑ Distance to nearest 1Well '''/1! . .,Foundation r Property Line <br /> SEEPAGE PITS .51 ✓� Depth cp1S i Size***33 sI [Numher Ni <br /> SUMPS Distance to nearest: We11� A A,- Foundation "34 f Property Line Ar <br /> DISPOSAL PONDS �� �' r t '+� r•' <br /> 1 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 regul.ations,of the,San,Joaquin.wLocal 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-certifies-the following: "I certify that in the performance of the work for which <br /> this permit` is issued, 1 shall employ persons subjectito workman's compensation laws of California." <br /> The applicant must call for all required inspections. Complete drawing'on reverse side. <br /> Signed X Title: Date: 41 <br /> FOR R T USE ONLY ` <br /> Application Accepted by Area Stk 466-6781 <br /> ti <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspecti Date Manteca 823-7104 <br /> Final Inspection by <br /> Dateu-� ❑ Tracy 835-6385 I <br /> r <br /> Applicant - Return all cop to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO L 4 ,s <br /> EH i3-24 REV. 10/82 (! 10/82 500 <br /> 14-26 <br />