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APPLICATION FDR,PERMiT � ' <br /> SAN JOAQU01 LOCAL,HEALTH JISTRIC <br /> 1601 E. HAZELTON AVE:, STOCKT ERMIT NO. <br /> Telephone (209) 466-6781 _ �+- DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE D �� 6 <br /> L <br /> (Complete in Triplicate,) AAnny5 �QUr1v LCQ(c+;TX <br /> Application is hereby made to the San Joaquin Local Health District for a perrylt+�Cb o�1.,qqu�c� bPlinstall the work herein <br /> described. This application is made in compliance with San Joaquin County OrdiWIL 1' 49 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of tt+he, San Joaquin Local Health District, <br /> Job Address Z73 I• lth,TOY'd Ave, S tSubdivision Name, # <br /> Owner's Name Address L. CZO..-1 hone <br /> Contractor's Name Punriance Drillers Driilirtigt�tlir3�nse No. r 95a3one ��? -3SS <br /> TYPE OF WELL/PUMP WORK: NEW,WELL WELL REPLACEMENT F DESTRUCTION <br /> PUMP 1NSTRLAT10N SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> T CSF Yh <br /> Industr"ial L.J Open Bottom ❑Manteca M Dia.. of Well Excavation <br /> Domestic/Private . .Q Gravel Pack Tracy Dia. of Well Casing <br /> Public f-1 Other EJ Delta Type of Casing g? <br /> U Irrigation Approx. Eastern Specifications (' <br /> Cathodic ProtectionDepth <br /> . � Depth of Grout Seal <br /> Geophysical Type of Grout UJ <br /> LJ Other Surface Seal Installed by <br /> Repair Work Done [� Type of Pumpf ..3i H.P. k:) <br /> - state Work Done ; <br /> Well Destruction ❑ Well DiaMEtenl Sealing Material (tap 50') — <br /> Depth it Filler Material (Below 50') <br /> TYPE OF,SEPTIC WORK: NEW INSTALLION ElREPAIR/ADDITION ❑ (No septic tank or seepage piavailableewithinubl200cfeet.sewe) is <br /> AT <br /> Installation will serve: Residence — Commercial _ Other <br /> Number of living units: 'Number of bedrooms Lot size <br /> r Character of soil to,a depth of;3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg <br /> Capacity Np ,Compartments <br /> f PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> Property Line F+ <br /> SEWAGE SYSTEM Distance�:to nearest: Well Foundation Pro P <br /> DESTRUCTION i *. <br /> LEACHING LINE U No. & Length of linesTotal length/size "'• <br /> 4Pro erty Line <br /> FILTER BED ❑ Distance to nearest: ,Well r Foundation P f <br /> SEEPAGE PITS [j Depth .l Size `` Number <br /> SUMPS J — LJ Distance to`'nearest: 41e11 w ° Foundation Property Line• <br /> DISPOSAL PONDS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county <br /> I[ ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />€ Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman t, compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which <br /> this permit is issue I s employ persons subject to workman's compensation laws of California." <br /> �VThe appli usi`c for 11 required inspections. Complete dr ing on rev se si(d <br /> k Signed X <br /> ' Title: Or— Date r <br /> ffi O DEP TME E ONLYStk 466-6781 <br /> Application Accepted by Area r <br /> Lodi 369-3621 <br /> Additional Comments: <br /> t Date Manteca 823-7104 <br /> Pit or Grout Inspection <br /> ilk <br /> Final Inspection by' - Date L7Tracy 835-6385 <br /> Applicant Return all copies to-: 'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT .'AUE AMOUNT REMITTED RECEIVED BY DATE <br /> PERMIT NO. <br /> INFO � ` <br /> 14.S <br /> 10182 500 <br /> EH 13-24 REV, 10/82 <br /> 14-26 <br /> -x <br />