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APPLICATION FOR PERMIT <br /> SAN UOAQUiN LOCAL HEALTH DISTRICT N0. 7-w 7 --:13 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT <br /> JI l <br /> Telephone (209) 466-6781 DATE ISSUED 1 D/ <br /> i! <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. - <br /> (Complete in Tripl-icate) 4 <br /> , <br /> he <br /> rein <br /> Application is hereb1immadeotolsthe <br /> San <br /> Joaquin <br /> ance wHthlSanth DJoaqucn Countyt for a pOrdinanermit �ecNo5t549tfordsewagesorlNot. 1862rfor ewell/pump <br /> described. This app I1 <br /> and the.Rules and Regulations of the�San�quin cal Healt District. <br /> Jab Address /O ��[s• division Name <br /> ddr sI ill Phone <br /> A <br /> Owner's Name • <br /> License No. Phone ' <br /> Contractor's Name <br /> s <br /> a <br /> TYPE OF WELL/PUMP WORK: NEW;WELL WELL REPLACEMENT DESTRUCTION <br /> - - �_ <br /> PUMP INSTALLATION SYSTEM REPAIR -OTHER-LJ"'� <br /> - <br /> DISPOSAL FLD. PR <br /> OTHER WOP. LINE , <br /> DISTANCE TO NEAREST:_ SEPTIC TANK _� J�,SEWER_LINES PITS/SUMPS <br /> WELL ` <br /> FOUNDATION AGRICULTURE WELL` <br /> SPECIFICATIONS <br /> INTENDED USE TY?E OF WELL PROBLEM ARE <br /> CONSTRUCTION <br /> A f <br /> IJ <br /> U Open Bottom industrial <br /> []Manteca Dia, of Well Excavation <br /> T 03 <br /> Domestic/Private E] Gravel Pack Tracy Dia. of Well Casing p w <br /> Public [-j Other, Delta Type of Casing <br /> L iIrrigation Approx. Eastern Specifications Q <br /> Depth Depth of Grout Seal (i <br /> Cathodic Protection �- <br /> Geophysical c Type of Grout <br /> U Other 'f Surface-Sea) <br /> Installed by <br /> State-Work-Done•� .^�:.'_'"'-' <br /> Repair'W6rk Dane [J Type-of Pump., .�„.�.._ _H.P: "'".' ___'.. -.r — <br /> 5ealing Material (top 50') <br /> Well Destruction ❑ Well Diameter F <br /> pepth � r_, * ". Filler Material (Below 50') <br /> SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION 17"1 (No septic tank or seepage pit permitted if public sewer i5 <br /> TYPE OF <br /> ee T available within 200 feet.) <br /> 4 j <br /> t Installation will serve: Residence Commercial Other <br /> Number of bedroam� ` tot'size <br /> Number of living units: A_ Water table depth <br /> r Character of soil to a depth of feet: Ca aci No. Compartments — <br /> F - P r <br /> 1 SEPTIC TANK Type/Mf9 Cagacity Method of Disposal I `, <br /> PKC. TREATMENT PLT. � Type/Mfg Property Line S_ _ V" <br /> /—Foundation r <br /> SEWAGE SYSTEM � Distance to nearesf: aWel,l..-��� --•-k — <br /> DESTRUCTION -_"f . <br /> — Total length/size <br /> LEACHING LINE U No. & Length of lines <br /> r Foundation` _ _._ Property Line <br /> FILTER BED U Distance to nearest: Well <br /> SEEPAGE PITS ❑ Depth -1 <br /> Size Number <br /> SUMPS �� Distance to nearest: Well <br /> Foundation Property Line <br /> k DISPOSAL PONDS ❑ I •S <br /> tf I hereby certify <br /> ethat <br /> I have <br /> rulespre-pared <br /> d this <br /> regulations nand <br /> the that <br /> ri the <br /> nwork <br /> will <br /> be done in accordance with San Joaquin county <br /> and! <br /> ordinances, stat that <br /> !!! <br /> home owner or licensed agent's 'signature certifies the <br /> fol mannertheto become subject ntohworpkman�compensatnce of lionwlaws ork fof California." <br /> permit is issued, I shall not employ any p 1 performance of the work for whit <br /> Contractor's hiring or sub-contracting signature <br /> bjectcert,toeworkman'ss the lcompensation rlaws of California." <br /> this permit is issu d, S shall employ p <br /> The applicant must l fo re 'red spections.Complete drawing on reverse sid'e'. pate: <br /> Title: <br /> I Signed X 11 <br /> FOR DEPARTMENT USE ONLY Stk 466-6781 <br /> Application Accepted by onf ,♦<}g .,� Lodi 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> r <br /> t Pit or,Grout lnspection by pate �' 7/f ❑ Tracy 835-6385 <br /> Final Inspection by °I <br /> r <br /> Applicant - Return all copies ti: Environ al Health Permit/services 160 E, az itis ve., P.O. Box 2009, St k., CA 95201 <br /> RECEIVED 8Y DATE PERMIT NO. <br /> EFEEOBASEAMOUNT, DUEAMOUNT REMITTED 5) <br /> 10/82 500 <br /> 1 EH 13-24 REV. 10/82 <br /> 14-26 <br />