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4 - APPLICATION FOR.PERMIT
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<br />SAN JOAQUIN LOCAL,HEALTH DISTRICT
<br />�, dusYrial. ❑ Upen-Bottom a u❑ MantecaI.JeDia. of Well Excavation
<br />STOCKTON
<br />1601 E. HAZELTON'AVE.. , CA PERMIT N0.
<br />Domestic/Private ;,'Gravelck` ❑ Tracy w�Dia of Well Casing `' =
<br />Telephone 4209j•466-6781, t►x
<br />DATE ISSUED
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<br />PERMIT EXPIRES" 1 YEAR fROM DATE 155UED ."� '," z,r?i +*'
<br />41.4e��in°riplicatej
<br />(Compl-etto
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<br />h�C�,n� 4K+.•' �j'.p3'9 �...:.'��+yini ll' -t .$f ,?wo k -:. { Yi--•'.
<br />9istritt fir perm to construct�andyor the work herein
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<br />Applicationis hereb" made t�o�tthe,SanJoaquinLocal:Health gnstall
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<br />This is made an compliance with San Joaquin County Ordinance No 549 for sewage or No 1862 fo
<br />described. application
<br />the Rules and Regulations, of. ihetiSan Joaquin Lacal Health Dis ict_
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<br />and a , .? we
<br />ame.
<br />Job Address
<br />Owner's ,Address x res �.� Phone
<br />,::.•: Phone .rind. -�I3�
<br />Contractor's Name `; LiCense.No.
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<br />TYPE OF WELL/PUMP WORK. NEW.WELL �' WELL REPLACEMENT[+ DESTRUCTION❑
<br />. -.-PUMP; INSTALLATION -. SYSTEM REPAIR OTHER ❑
<br />XO PRDP LINE
<br />`
<br />• DISTANCE TO NEAREST:.SEPTIC.TANK SEWER LINES ;"" DISPOSAL.FLD .
<br />'PITS/SUMPS�0
<br />FOUNDATION AGRICULTURE WfLt OTHER WELL
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<br />- 'INTENDED -USE "TY?E OF�WELL -:-:- PROBLEM AREAL'CONSTRUCTION SPECIFICATIONS
<br />�, dusYrial. ❑ Upen-Bottom a u❑ MantecaI.JeDia. of Well Excavation
<br />Domestic/Private ;,'Gravelck` ❑ Tracy w�Dia of Well Casing `' =
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<br />- �
<br />Public f Other}; -> . ❑ <
<br />- - ❑ ,r �.,• bel to � ;. *, ? '� `� TYPn of Casing.
<br />�
<br />:Lpprj irrigation - .a ' -"A ox �^"�°❑ Easternc Spedations f1
<br />Cathodic Protection Depth
<br />. ,,.�.,�-�-,�, ,:�---*r-+=�•- �--�*'�� :� E�-� '..�pth Sf `Grout"SeaT""��,7 - � •.. � �'
<br />of Grout" " . ...._.,
<br />Geophysical ~❑,r i a3 TY
<br />pe
<br />- "•� - r+A ..
<br />!❑Other t...,y Surface Seal Installed .by IW~�
<br />Repair Work Done ❑ Type of Pump • H.P. Work Done
<br />Sealing Material (top 50aie
<br />' Well Destruction ❑ Well ,Diameter, 9 -
<br />'
<br />Depth 4 Filler Material .(Below 509
<br />TYPE OF SEPTIC WORK:' . NEW INSTALLATION ❑ REPAIR/ADDITION ❑ .(ND septic tank or ,seepage pit permitted jf.publio°sewer is
<br />-within 20 )
<br />- ilable0 feet
<br />r
<br />cava
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<br />L> `.Installation will ,serve -' Resj.
<br />idence ;Commercial Other" ,p �„t
<br />�: s Lot ;.
<br />Number of living units: Number of bedrooms f., Ar
<br />.'Water table depth .
<br />' Character of soil to a.depth of 3 feet >. ,
<br />�H oCompartments,
<br />.SEPTIC ❑TY"Pe M9.Capacity ty
<br />Method of Disposal'_Catity
<br />apM
<br />APGfg•, r
<br />SEWAGE.SYSTEM Distance-to,nearest 'Well. --L!,_ Foundation P.roperty;:Line
<br />DESTRUCTIONyy,
<br />lines
<br />'LEACHING -LINE • ❑ 'No: E'Length of -lines-
<br />-Distance to nearest. z)A0l1 ,-4 oundation y Property:.l_ine �
<br />-Di
<br />jIL'TER_BED ❑ ,. ;.- ---�— �-----_
<br />size ; umher:`a
<br />6 SEEPAGE PITS : i;Deiql�pth "
<br />-
<br />` Property
<br />-
<br />' SUMPS ❑ Distance to nearest:..i.'Well �F� Foundation --,Line
<br />«,
<br />,1E_ ".SI
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<br />.: "DISPOS -- ..�..... -� .;,,,a•-*t"_•�.-t" ice. �
<br />I hereby certify that I have.prepare-dIthis application and that the work will be done .in accordance withrSan.Joaquin county
<br />ordinances,':=state laws, and ;rules and:regulations.of the Sam Joaquan Local Health District .�;... r
<br />Home owner or licensed agent's>signature:certifies the following: "I"'certify_that ifi-the performance of the work'for yrhich this
<br />'permit is issued, l shall not employ any person in -such manner as to become=subject .to workmanK compensation ';1aws'bf 'California." t
<br />:Contractor.'s-hiring 'or sub -contracting signature Certifies'thefollowing:""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 offal fornia 4
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<br />''The applicant mus I f ections �pomplete drawing on reverse side.
<br />F {#
<br />.,
<br />{ e Oate
<br />""`� Title• .
<br />Signed X y •.
<br />ARTMENT USE NLY �s
<br />17 Area, f [j 5tk 466-6781
<br />"f Application epted by Lodi ','369 3621
<br />r ?. Additional. Comments.
<br />Pit or Grout ]nspection by Date j Manteca 823-7104
<br />ion by
<br />-final inspect
<br />4late r Q 'Tracy -4.835
<br />Applicant Return all copies to::: Environmental Health Permit/Servlces.1601 E Haze on AYe.;.-P O Box 2009,'Stk.; to 952Di
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<br />FEE -BASE. AMOUNT .DUE AMOUNT?REMITTED'_ RECEIVED BY" -. ,,. DATE.
<br />PERMIT NO.-.;
<br />INFO r...r
<br />r - ' I . ' 10/82 500
<br />EH 13=24 REV: 10/82'
<br />14-26 !
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