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4 APPLICATION FOR PERMIT <br /> SAN IOAQUIN LOCAL HEALTH.DISTRICT <br /> r 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. F3 <br />` Telephone (209) 466-6781 DATE ISSUFD 7�� <br /> PERMIT EXPIRES 1 YEAR FROM DATE 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 comp549 for sewage or No. 1862 for well/pump <br /> compliance with San Joaquin County Ordinance No. <br /> and the Rules and Regulations.of the San Joaquin Local Health District. pp__ ww W <br /> Subdivision Name �rG1 /C <br /> Jab Address Phone <br /> a Owner's Name q Address _l <br /> a <br /> Contractor's Name /6912 j "cs License No. ,�` -3Phone yob—X607 <br /> TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION <br /> r PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DI5TANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL- PR -AREA <br /> y CONSTRUCTION .SPECIFICATIONS <br /> Industrial r F-1 Open;Bottom ❑Manteca <br /> `Dia, of Weil`Ezcavation ` <br /> ❑ Domestic/Private F-1Gravel Pack E] Tracy Dia. of Well Casing <br /> ❑•Public € F-1Other N Delta g <br /> ❑ Type of Casing <br /> Ll Irrigation Approx. Eastern ". <br /> ❑ Specifications , <br /> ❑Cathodic Protection <br /> Depth, Depth of Grout Seal <br /> Geophysical Type of Grout <br /> - LJ Other i � Surface Seal Installed by <br /> Repai,r.Work Done ❑ Type of Pump ' H.P. State Work Done <br /> Wehl Destruction ❑ Well Diameteri I Sealing Material (tap 50') i._ <br /> Depth !r Filler Material (Below 501 <br /> ti /V <br /> Fr TYPE OF SEPTIC WORK: NEW INSTALLATION� l REPAIR/ADDITION ❑ (No septic tank or seepage P,availableewithiPu20Ocfeete) is T <br /> rInstallation will serve: -Residence _ Commercials Other <br /> 4 Number of living units:4-doliSS Number of bedrooms of size /We.� <br /> RR.• ; . *Water 6bl6:de)h 1,119 <br /> Character of soil to a depth of 3 feet: ...59 <br /> e Capacity 2�Q[� No. Compartments `L- <br /> T L' <br /> SEPTIC TANK IF yP /Mf 91: -- ---- - — <br /> c <br /> PKG. TREATMENT PLT. F-1 Type/Mfg <br /> Capacity y <br /> r SEWAGE SYSTEM C1 Distance to nearest: We11IR-2941e- Foundation 20 <br /> � Property Line <br /> DESTRUCTION 3 -.4 <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size �� ali� , <br /> Property n FILTER BED � Distance to nearest: Well •-�' Foundati.on 2 O P erty Line <br /> SEEPAGE PITS <br /> Depth Size Number <br /> ❑ P � <br /> Distance to nearProperty Line <br /> est: Well Foundation <br /> SUMPS lJ _ s <br /> ' DISPOSAL PONDS ❑ _� <br /> I hereby certify that I have prepared this applieation-and that the work_will_beµdone in accordance w9,th San Joaquin county <br /> ordinances, state laws, and rules and regu_hations of the�San Joaquin Local Health District. f <br /> Home owner or licensed agent's signature Gerson en�uchfmannernaslto�becomeysubjeetthat ntohwopkma� c-0mpensatrmance of ionwlawsfof California." <br /> permit is issued, I shall not employ any p <br /> Contractor's hiring or sub-contracting.signature certifies the fallowing: "1 certify that in the performance af`the work for whit <br /> this permit is issued, 1 shall employ persons subject to workman's compensation laws of California. N � <br /> I ` <br /> The applicant must c 11 for all req a inspections. Complete drawing�e never side. 1 <br /> i t 1 <br /> Signed X oL/ r <br /> F R•DEPARTMENT USE ONLY ti A a �f� w i Q Stk: „..466-678 1 <br /> Application Accepted by <br /> ; � �,l ❑ Lodi 369-3621 <br /> Additional Comments: �+-+ - Manteca BZ3-7104 <br /> Pit or Grout Inspection by Date <br /> Final`Inspection by ��r ` <br /> Date .1�� ❑ Tracy 835-6385 <br /> Applicant - Retrirn al,l copies moo: tnvit nmentalYHealth .P.ermit/ServiCes`16D1 E� HazeltonAve4,{ 0: '8o s,2004 Stk., CA 95201 <br /> RECEIVED BY DATE PERMIT NO. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED r <br /> } <br /> INFO e -S_Cso _ _ <br /> 10/82 500 :. . <br /> EH 13-24 ?LV1-10/ 2 �� <br /> 14-26 <br /> w <br />