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APPLICATION FOR„PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Tel ephone.(209•);466:=.6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE.•ISSUED , <br /> i <br /> (Complete in Triplicate) } <br /> Application is hereby made-to the San Joaquin Local Health District fer'a permit to construct and/or install the work herein <br /> described, This application is mad6lin compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1862 for well/pump <br /> and the Rules and Regulations of the.isan Joaquin Local He lth District. <br /> Job Address +) /subdivision Name d Q a/cL, <br /> Owner's Name C 1 . .0 ess 41f 1-+44 t /161 d af/L�IxL� . Phone <br /> -> _ <br /> Contractor's Name -Q r } C airy License No. e,j f/ 2 3-7 3 7' Phone ”/a- � <br /> .:t� W W <br /> TYPE OF WELL/PUMP WORK: NEN WELL WELL REPLACEMENT DESTRUCTION'S <br /> PUMP ]NSTALLAT19N � SYSTEM REPAIR +� ��OTHER.;U `1 /, e <br /> DISTANCE TO NEAREST: SEPTIC TANK /QD SEWER LINES 16-0 4- DISPOSAL FLD"` /UQ'f PROP. LINE �Q 4- � 4�' W <br /> FOUNDATION AGRICULTURE WELL`ll�_ OTHER WELL PITS/SUMPS Q <br /> INTENDED USE TYPE CO WELL PROBLEM AREA'S,' }� CONSTRUCTION SPECIFICATIONS <br /> Jlndustrial U Open Bottom E] Manteca, Dia. of Well Excavation O <br /> L} Domestic/Private k<rave1 Pack Tracy Dia. of Well Casing <br /> Pub,l is <br /> ❑ "I �jOthef � � Delta Type of Casing <br /> F!errig'a,tion �. Approx. Eastern ' <br /> '`" Depth � Specifications ,+ <br /> Cathodic''Protection � <br /> " Depth of Grout Seal � [a/ ; <br /> �,�Geophysical'< 4 J11 <br /> Type of Grout N�p�•a^—► <br /> Other ,� Surface Seal Installed by Q�� J4, <br /> / <br /> Repair Work}-Done EJ Type of Pump , JL ti H.P. State Work Done f f— <br /> ` Wel}' Destruction U Well,Diameter `1 Sealing Material (top 501) <br /> Depth f Filler Material (Below 50') <br /> TYPEE'OF SEPTIC WORK-:1 NEW INSTALLATION ❑ REPAIR/A[YDITION­E—]_(No septic tank or seepage pit permitted if public sewer is <br /> x `- 11 --ava•i-fable-within•200 feet.) <br /> Installation wiAl serve: Residence _ Commercial Other ` <br /> m . <br /> 'S, Number of Iii-,Ing-units: Number of bedrooms Lot size <br /> `,:Character of soil to a depth of 3 feet: Water table depth <br /> \ �"`' '� No. Compartments - h <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> r <br /> PKG. TREATMENT PLT, F-1 Type/Mfg t Capacity Method of Disposal ._,. <br /> SEWAGE SYSTEM ' Distance t'oinearest: Well Foundation ; :Property Line <br /> DESTAOCTION <br /> LEACHING LINE U No. & Length of lines Total,i..length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE-'PITS ❑ Depth 1 Size Number <br /> SUMPS R ; U Distance to nearest: Well Foundation Property Line A <br /> DISPOSAL PONDS ED <br /> [-hereby certify that I have prepared this application and that the work will be done in accordance with dan"Joaquin county <br /> ordinances, st s, and rules a,n,d regulations of the San Joaquin Local Health District. r,ra <br /> Home owner license agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit i ,issued, I sh 11 not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contra or's hiring or ub-contrac ing si ture certifies the following: "I certify that in the performance of the work for which <br /> ' -this rmi•t is 'ssued, I shall e ns subject to workman's compensation laws of California." <br /> -'The a plicant st 1 for 1 in spec ons. Complete dr�►ging on r r side. <br /> SignTitle: <br /> ��^+ Date: .57-- <br /> eL � <br /> Apeor '- R DEPA MENT USE ONLY <br /> l-ication Accepted by Area [V'Stk ,466-6781 <br /> 21r+1.5.iq,`;`�Rddltional Comments: V Lodir' 369-3621 i <br /> Pitor Grout Inspection by ![ Date _ Manteca 823-7104 <br /> 0-1� Fina h Inspection by - ;, Date L Tracy 835-6385 k <br /> ? Applicant -.Return all copies to:­'Environmental Health Permit/Services 1601'E. Hazelton Ave., P.O. sox 2009, Stk., CA 95201 f <br /> FEE BASET —AMOUNT DUE AMOUNT REMITTED' RECEIVED BY DATE PERMIT NO. <br /> INFO 1 <br /> `9 <br /> EH 13-24 REV.?10182 f 10/82 500 <br /> 14-26 <br />