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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DLSTRICT <br /> PERMIT NO. <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (249) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) µ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> with San Joaquin County Ordinance No. 549 far sewage or No. 1862 for well/pump <br /> described, This application is made in compliance : <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address 7 � �' "�E�/�T � -CL f? AN Subdi isian Name !! s 1 <br /> S DI.B€x 8 p- !�° S Phone <br /> Address -35S <br /> Owner's Name 32 3 Phone <br /> Contractor's Name <br /> License No. . <br /> TYPE OF WELL/PUMP WORK: NEN WELL WELL REPLACEMENT. DESTRUCTION <br /> r PUMP INSTALLATION SYSTEM REPAIR .�7 OTHER U <br /> DISPOSAL FED. PROP. LINE <br /> DISTANCE,TO.NEAREST.' SEPTIC TANK _ ^� SEWER LINES ER WEL <br /> PITS/SUMPS <br /> AGRICULTURE WELL OTHER �_ <br /> FOUNDATION rt <br /> Ilk <br /> CONSTRUCTION SPECIFICATIONS -« I <br /> INTENDED USE TYPE OF WELL x PROBLEM AREA "",Dia. of Well Excavation 0 <br /> �y _ -`� <br /> Indusrriea u Open "Bottom [f Manteca <br /> Tracy Dia. of Well Casing _ <br /> Domestic/Private �.k "F-1 Gravel ,Pack O <br /> Public [j Other []Delta Type of Casing <br /> k Irrigation Approx. Eastern Specifications (s, <br /> Cathodic Protection <br /> Depth Depth of Grout Seal v�J <br /> Geophysical Type of Grout <br /> L J Other ' Surface Seal Installed by <br /> T of Pump _ _._ H•P• S State Work Done 1rnS�'1j G(•+A <br /> Repair Work Done Type �s <br /> well Destruction U Well Diameter <br /> Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> d if <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION El REPAIR/ADDITION J (No septic tank or seepage p�availablewithinpublic <br /> within200�feet.) is <br /> Other f <br /> Installation will serve: Residence Commercial Lot size <br /> i <br /> Number of living units: Number of bedrooms --�"� Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑' Type/Mfg Capacity Method of Disposal <br /> k k F �_�_ <br /> PKG. TREATMENT PLT. Type/Mfg Foundation Property Line <br /> ' SEWAGE SYSTEM Distance to nearest: Well <br /> DESTRUCTION F�' <br /> Total length/size -• , <br /> LEACHING LINE U No. & Length of lines property Line <br /> FILTER BED �_- <br /> Distance to nearest: Well Foundation <br /> Size Number - -- <br /> SEEPAGE PITSLD <br /> . ;Depth --,--- -_ -- - Property L <br /> SUMPS L-I <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have <br /> rurepared this <br /> regulations the SanhJoaquinwLocalork �Heall lthdDistricte in ccordance with San Joaquin county <br /> ordinances, state , and that <br /> Home owner or licensed agent's signature ctifies thesucfolio Inas to become subjectntohwopkman� compensaterformance of ionwlaws ork fof Califoror which this <br /> nia." <br /> permit is issued, I shall not employ any person <br /> -Contractor's hiring or lushalltemploygpersoatuns subject�toeworkmas the eslccompensationrlaws ofaCalrifornithe aerformance of the work for whit <br /> f this permit is issued, <br /> 1 ' muet�cal �1 required inspections, Complete draw ng onn reverse'side. <br /> Date:The aPP <br /> �� � -,• Title:: <br /> I Signed t �` <br /> EPARTMENT USE ONLY Stk 4�5Z > <br /> A�;. Ol C ,4 ... <br /> Application Acc pted by 3936L1 <br /> Lodi ,. -�-, .� <br /> Additional Comments: r Date' .Manteca 8, 3704 = " <br /> S/ r^. <br /> Pit or Grout Inspection by ` f ��` Tracy; gS=Cs385 s.., <br /> S: Date �J <br /> Final inspection by dI1, P.O. Box 2009 •, CA9520 <br /> Applicant.- Return all copies to: . Environmental alth Permit/Services 1601 E. Hazelton Av ,N <br /> PERMZT� <br /> DATE <br /> k AMOUNT-REMITTED RECEIVED BY -1 <br /> FEE BASE AMOUNT DUE <br /> f INFO ;� - �G/1t11( �• k �. <br /> 0/8 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />