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"~ti• 3 F <br /> APPLICATION FOR PERMIT <br /> SAN JOA QU;N LOCAL HEALTH DISTRICT PERMIT No. T LA- LA 31a <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781' DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR_FROM.DATF ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the,Rules and Regulations tions-of the San Joaquin Local Health District. <br /> J�YL�/y Subdivision Name <br /> Job Address ��.�Phone <br /> Add ess <br /> Owner's Name Phone <br /> wa bLicense No. <br /> Contractor's Name <br /> i o JS <br /> WELL REPLACEMENT Q DESTRUCTION <br /> TYPE OF WELL/PUMP IJORK: NEW WELL OTHER U <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7_SEWER <br /> LINE <br /> SEWER LINES DISPOSAL FLO, <br /> /D`ISTANCE TO NEARESI3:' SEPTIC-TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL _�� <br /> n CONSTRUCTION SPECIFICATIONS <br /> .INTENDED USE' <br /> TYPE OF WELL PROBLf EM AREA <br /> 0 i6ottom ❑ Manteca pia, of Well Excavation <br /> en <br /> Industrial U p f r Dia. of Well Casing <br /> Domestic/Private �]Gravel Pack TracyF-I -- e <br />{ Public [j Other ❑ Delta Type of Casing <br /> I Irrigation Approx. Eastern '. Specifications <br /> Depthpepth of Grout Seal 1 <br /> Q Cathodic Protection V" <br /> Geophysical 'Type-ofGrout <br /> # Surface Seal Installed by �_� <br /> ❑other <br /> H P State Work-Do <br /> ne— <br /> Repair Work Done TyPe of Pump �, <br /> Well Destruction Well Diametj Sealing Material (top 5O')� <br /> Depth Filler Materia} {Below 5W'�.. + k -�� �C <br /> EPAI DDITION U (No septic tank G-.cr seepage pit permitted if''public sCwer is <br /> -rr- available within 26O fee • „ � <br /> TYPE OF SEPTIC WORK: NEW INS TALjAT10N U t <br /> Commercial Other <br /> 'r Installation will serve: Residence Lot size <br /> —� <br /> t Number of bedrooms s y <br /> Number of living units: 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 /> PKG. TREATMENT PLT. ❑ Type/Mfg Foundation Property Line w <br /> SEWAGE SYSTEM Distance to nearest: Well <br /> DESTRUCTION dotal length/size <br /> LEACHING LINE <br /> No. &'Length of lines Property'Line <br /> IJ ,Foundation <br /> � FILTER BED 0 Distance to nearest: Well <br /> Number v�- . <br /> SEEPAGE PITS Depth."._ _ size Property-Line <br /> ` `"1� Foundation _. . <br /> SUMPS <br /> Distance to nearest: Well �_C��-r'- a <br /> DISPOSAL PONDS Cl } <br /> k34 that I have prepared this application an that,fhenwork will <br /> HealthdDnstrnctccord ncew fhthe workgfor whuin ich this <br /> f I hereby certify of <br /> ordinances, state laws, and rules and regulations <br /> n person in such manner-as to become subject to workman compensation laws of California." <br /> Home owner or licensed agent's.signature certifies the following: 1 certify that in the per or <br /> permit is issued, I shall not employ any p <br /> la persons subject to workman''s compensation laws of California." <br /> Contractor's hiring or sub-Contracting signature certifies the�fa110wing: I certify that in the performance of the work for which <br /> this permit is issued, 1 ohall'ere Y P Complete drawing on reverse side. r� <br /> The applicant t call for 1 required inspections. Title: Date: <br /> f Title: _ <br /> Signed X466-6781 ''ham, <br /> FOR EP RTMENT USE ONLY Area � 5tk _ <br /> Application Accepted by' Lodi 369-3621 <br /> Additional Comments: )! r (` Manteca 823-738 i <br /> �: ate J <br /> P <br /> or Grout Inspectign by _ Tracy 835-6385 <br /> Date 4. <br /> tnal Inspection by _ �, <br /> Return <br /> all copies to: Environmental e Ith Pe it/Services 1601 Hazelton Ave P.O. Box 2609, Stk., CA 95201 <br /> Applicant - / PERMIT N0. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE <br /> 1 INFO �'I 'SC <br /> S'� 0 10/82 500 <br /> i <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />