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1 <br /> APPLICATION FOR PERMIT <br /> S�.fJ -,OAQUIN LDCA. HEALTH ;IS-iRICT � 79 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. / <br /> Telephone ('209} 466-6781 DATE ISSUED <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in,Triplicate) <br /> A licatio"h is hereby made to the;"San Joaquin Local Health District for a pe dinan�ecNoSt549tfordsewagesorlNoth1862rforewell/pump <br /> rein <br /> Pp n e with San Joaquin County Or <br /> descrtbed, This application is made in compliance <br /> i the San )oaouincLocal Health District: <br /> and the Rules and Regulations of <br /> Job Address sQ- Subdivision Name <br /> i 7 Address tr /r od.QP Phone <br /> IE Owner's Name � S�!C'�' Phone <br /> �' <br /> License No.. <br /> Contractor's Namech <br /> Z <br /> REPLACEMENT DESTRUCTION <br /> TYPE OF WELL/PUMP WORK: �,µ�:. NEbJ WELL a, +. 1 <br /> r' <br /> P--UMP.INSTALLAT-10N,.Ei,.SYS�T-eEM, REPAIR,`1 ❑ OTHER <br /> U <br /> DISTANCE TO NEAREST: SEPTIC TANK, "� 1. tSEWER LINES-.,_ g.° <br /> DISPOSAL FLD. PROP. LINE <br /> OTHER WELL ?ITS/SUMPS d <br /> FOUNDATION AGRICULTURE WELL.^,__+ti. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON5TRUCTdnN'SPECIFICATIONS C16 <br /> Dia. of Well Excavation -.. <br /> �J Industrial U Open Bottom D Manteca y- r, <br /> U Domestic/Private Gravel Pack [j Tracy r ; Dia. of Well Casing <br /> Public Other,, ❑ Delta Type of Casing <br /> 'i Irrigation A Other,, <br /> Eastern Specifications' <br /> k a <br /> Cthodic Protections ;` ;E ' Depth ° <br /> f fi Depth of-Grout Seal <br /> Geophysical Type of Grout' <br /> ' ❑Other r-r "k . Surface SealrInstalled by <br /> 41 <br /> * H.P. State-.Work Done <br /> � <br /> Repair Work Done^�� Type of�Pump - y <br /> Well Destruction [—I Well Diameter Sealing Material (top 50')' .. <br /> 4 Depth a ' Filler Material (Below 50'} a <br /> - -- m <br /> No septic tan du r seepage pit permitted if public sewer is <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION �{ REPAIR/ADDITION LJ ( T available within 200 feet.) <br /> installation ll serve: Residence _� lommercial _ Other a• <br /> y <br /> I Number of living unit�i.Y0 Number_of bedrooms_., _ y I_o�ize w <br /> 4 w m.; ot Water°-table depth <br /> Character of soil to a depth of 3 feet: � No Compartments <br /> SEPTIC TANK K Type/Mfg / Capacity <br /> PKC. TREATMENT PLT. ❑ Type/Mfg <br /> ` ,., Capacity Method of Disposal <br /> -�^ Property Line <br /> SEWAGE SYSTEM � Distance to nearest: Well Foundation <br /> y <br /> DESTRUCTION - <br /> LEACHING LINE Q No: `J§+L�gth`�offlines est: Well <br /> Total length/size <br /> FILTER BED �,. ' Distance to near <br /> "• -'46undation } Property Line <br /> 1 —Ik Number <br /> 4 SEEPAGE PITS � Depth "�; Size _ <br /> SUMPS �:'' �� Distance to nearest: ' Well <br /> Foundation' Property Line <br /> DISPOSAL PONDS <br /> cordance with San Joaquin county <br /> I hereby certify that I have prepared this application and that the work will be done in ac <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certi <br /> suchFinannernas to became subjectthat ntohwopkman� compensaterformance of honwlaws fof California." <br /> permit is issued, I shall not employ any p <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certif jf` atwim-the performance of the work for whit <br /> ' <br /> this permit is issued, I shall employ persons subject to workman's compensation laws de California." <br /> The applicant must call r al quir nspections. Complete drawing on reverse side. Date. /~�✓ <br /> Title: (® <br /> Signed X <br /> FDEPARTMENT USE ONLY Area �_� Q Stk 466-6781 <br /> Application Accepted by Lodi 369-3621 <br /> Additional Comments: Date �anteca 823-7104 <br /> Pit or Grout Inspection by ❑ Tracy 835-6385 <br /> � <br /> Final Inspection by <br /> Date <br /> Applicant - Return all copies 601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> to: Environmental lth Permit/Services 1 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT{ N0. <br /> _IN FO <br /> EH 13-24 REV. 10/82 <br /> 14-26 °' <br />