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APPLICATION FOR�PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601 E. ,HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> x Tel-ephane (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES' 1 YEAR FROM DATE ISSUED <br /> (Complete in' Triplicate) 'I <br /> Application is hereby made to the San Joaquin Local Health District for a 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 of the San Joaquin LocalJigalth District. <br /> Job Address STI` ubdivision Name <br /> Owner's Name Address PHone <br /> Contractor's Name �` Cfc*rl5e No. Phone <br /> TYPE OF WELL/PUMP WORK: . NEW WELL WELL REPLACEMENT E] DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR El OTHER F-1 <br /> DISTANCE TO NEAREST:r SEPTIC TANK — f SEWER LINES DISPOSAL FLD. PROP. LINE _ -74 <br /> FOUNDATION �� AGRICULTURE WELL OTHER WELL PITSA2225 f �'Q 7 I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I rQl`n <br /> 17 Industrial ❑open Bottom E]Manteca Dia. of Well Excavation _ _ /Z�� <br /> U Domestic/Private 5apGravel Pack E]Tracy Dia. of Well Casing <br /> Public <br /> Irrigation CJ Other Delta Type of Casing <br /> Irri <br /> fJ g - -, jl-Apeprox�--Q-Eastei-n-• <br /> D _ 5peci#icatibns <br /> Cathodic Protection P w .. <br /> Geophysical <br /> Depth of Grout Seal q� <br /> — S -- <br /> Type of Grout (il <br /> Other - V 1 <br /> Surface Seal Installed by MME&2 WEAW PILL)IQ Z <br /> Repair Work Done E] Type of Pump H.P. _ State Work Done <br /> Well Destruction ❑ Well Diameter =+ F Sealing Material (top 50') <br /> Depth >, Filler,Material, (.Below 50') <br /> TYPEFOF SEPTIC WORK: NEW INSTALLATION [ "'REPAIR/ADDITION [f '(Nonseptic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other r <br /> Number of living units, Number of bedrooms Lot size r, <br /> Character of soil to a depth of 3 feet: Water table depth ss <br /> SEPTIC TANK , [j Type/Mfg Capacity No. Compartments r <br /> PKG: TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal ; <br /> SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line <br /> DESTRUCTION k <br /> LEACHING LINE [f No. & Length..of lines Total length/size <br /> FILTER BED; Distance to nearest: _Well--'"— Foundation Property Line <br /> SEEPAGE �'P,IT'S [ Depth ., I S.ixe Number 11 J <br /> Distance to nearest: Weil s' Foundation Property Line r 1 <br /> DISPOSAL PONDS <br /> r <br /> I hereby certify that I have prepared.this apphication and that the work will be done in accordance with San Joaquin county' <br /> 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 i.ssued,_I.shall not employ.any.person in such manner..as t-p-„become-Subject to workman§ compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following "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 of California." <br /> The applicant mu ca31 or al a uired inspections. Complete draw' g on everse side. <br /> F, - <br /> Signed X Title.:' � ����.. Date: 3 <br /> F R=-USE-40NLY <br /> �-.. `�ak,;,.ti <br /> Application Accepted by z.Area i' Stk . 466-6781 <br /> Additional Comments: ' 1 e/ Lodi 369-3621 <br /> Pit or Grout Inspection Date_ le -� Manteca 823-7104 t <br /> Final Inspection by .v. Date Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Seryices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEF BASE AMOUNT DUE AMOUNT REMITTED I--RECEIVED- <br /> BY DATE PERMIT N0, <br /> INFO <br /> ..�,..,� ...«� .�. �.... . -3'4�3 w .. <br /> EH 13-24 RI;Y. 10/82 10/82 500 <br /> k _14-26 <br /> ti <br />