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t <br /> APPLICATION FOR PERMIT p <br /> E SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> PERMIT N0. <br /> s 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781;, _ DATE ISSUED y fJJ i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ I <br /> 1 (Complete in Triplicate) 1 <br /> an /or intl the wok hrein <br /> Application is hereby made to the San Joagmi �iencelwlithlSaneathDJoaquin CountyQO dinancecNo. 549tford <br /> sewagesorl'No, 1862rfore <br /> well/pump <br /> described. This application is made in co p <br /> and the Rules and Regulation�of th San 3oa uin Local Health District, <br /> Subdivision Name r, <br /> Job Address Phone .� <br /> Address 3,9 33 <br /> Owner's Name Phone <br /> ,fid License No. <br /> E Contractor's Name �[ <br /> TYPE OF WELL/PUMP WORK: NE4JjAELL WELL REPLACEMENT DESTRUCTSON <br /> OTHER <br /> U <br /> PUMP INSTALLATION � SYSTEM REPAIR OPROP. L1NE <br /> E gSEWER LINES DISPOSAL FLD. <br />{ DISTANCE TO NEARESTr�SEPTIC TANK I �. OTHER WELL PITS/SUMPS <br /> FO � '`�RGRICULTURE WELL ___� — <br /> FOUNDATION RC1 <br /> GCONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> U Open�Bottom"' [-`—J-Man teca-DTa—of-Wel-l—Excavat ion— w .f <br /> Industrial .f <br /> ; Dia. of Well Casing <br /> Domestic/Private Gravel Pack [Tracy <br /> Public FlOther Q Delta Type of Casing <br /> Approx. ❑;, <br /> C Irrigation Eastern Specifications _ <br /> f JDepth Depth of Grout,Seal <br /> I �Cathodic Protection _ <br /> x Type of Grout <br /> Geophysical f. <br /> ` Surface Seal Installed by <br /> Other <br /> f ^�; I" H.P State Woi"k Done" : — <br /> Repair Work Done-[D, Type of Pump �.�� <br /> s r " Sealing Material (tap 50') f" <br /> Well.'.Destruction'U Well Diameter;— .% <br /> �' "#• Depth Filler Material (Below 50') <br /> it permitted if public sewer is .� <br /> �� <br /> .-REPAIR/ADDITION.` + *„ available within 200 feet.) <br /> TYPE OF'SEPTIC WORK: NEW INSTALLATION yNo septic tank or-seepage p <br /> .0- , <br /> (J Commercial Other " IS�V <br /> Installat-ion will. serve: Residence _ --�, <br /> ��' Lot size _�— .�, <br /> Number of bedrooms E ; Water table depth <br /> Number of living <br /> units: ' . <br /> 1 Character of soil to a'_ epth of �3 feet: r Capacity �d� V _ N0. Compartments <br /> SEPTIC TANK 'Type%Mfg. Method of Disposal <br /> { .x Capacity <br /> pKG. TREATMENT PLT. F�l Type/Mfg, Property Line <br /> ,t SEWAGE SYSTEM Distanceht0earest: WelilFoundation <br /> DESTRUCTION .. Totalil.ength/size <br /> N0. <br /> LEACHING LINE & Lengi;Wlof)lines -_�-. 1 <br /> f Property Line -Q--- <br /> Foundation r� <br /> FILTER EEO Distance to nearest: Well , �Fs�--- <br /> Size Number t <br /> SEEPAGE PITS [�` DeptYt_L __-_ . iProperty Line <br /> s . <br /> SUMPS ➢istatice,ta nearest: Foundation Well i <br /> DISPOSAL PONDS ❑ <br /> )plication and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this app ; erformance of the work for which this <br /> ordinances, state laws, and rules'and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's'signatuane', ersoniin suchs the {mannernas t° becomeythat subjectntohw•orkman�'compensatilawthefworkifornwhich <br /> Of <br /> permit is issued, 1 shall not employ y,,'P "h-certify that in the performance <br /> Contractor's hiring or sub-contracting signal subjecture �toeworkmans the �slpompensation laws of California." <br /> this permit wiS issued, I shallfempl0y p z s �� <br /> The applic�,M, ca for uired inspections. Complete drawing on reverseside Date: <br /> e:-, <br /> Signed X <br /> FOR DEPARTMENT USE ONLY 466-6781 <br /> A T E "; .. a.. Area a s <br /> Ap'pl icatio'Accepted bye * , �y4"..g ._� .; y °di 369-3621 <br /> r 4 r <br /> Additional Comments: _ Manteca 823-7104 <br /> Pit,or Grout .Inspection b to F ❑ Tracy 835-6385 <br /> Final Inspection by <br /> i t s Envi.r n enta. ,.Health�Permit/5_erv_ice5�1601_E;�Ha elto ?• <br /> Applicant - Return all copp;O �'B0x 2009, St k., CA . 95201 <br /> - <br /> - PERMIT N0. <br /> """""' OATEc <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY r/ <br /> INFO <br /> i 10/82 500 <br /> I EH 13-24 REV. 10/82 <br /> 14-26 iii ..... r <br />