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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZFLTON AVE., STOCKTON, CA 3 Z <br /> Telephone (209) 466-6781 PERMIT NO. <br /> PERMIT EXPIRES I YEAR- FROM DATE ISSUED DATE ISSUED: <br /> (Complete in Triplicate)Appi I; <br /> 1 <br /> described. is Thiseapplicateonoishmad,`eninoaquin eompliancelwHthlth SanDistrict for a Joaquin CountyPO herein <br /> and the Rules and Regulations of t'h'e. San Joaquin Local health District. } <br /> /Pump I <br /> Job Address 3 9 fe /j/m �R�, u M <br /> Subdivision Name <br /> Owner's Name �1P 5 e>-e Ae Address A <br /> Contractor's Name ' - �3 g� c` y014� 'C/ o4,Phone S 9 J -•Q <br /> - ,? � <br /> /y�ii7"/ian� � sem License No. s- <br /> Phone 5'�.t - V x <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT <br /> DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER U <br /> SEWER LINES DISPDSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREAIV <br /> CONSTRUCTION SPECIFICATIONS] Industrial U Open Bottom Manteca <br /> U Domestic/Private ] Dia. of Well Excavation <br /> [ Gravel Pack ❑ Tracy Dia, of Well Casing <br /> L—] Public F <br /> IrrigatiOther on E] f ❑ Delta Type of Casin <br /> Approx. [i Eastern g <br /> Cathodic Protection Depth Specifications <br /> L]Geophysical r Depth of Grout Seal <br /> L_JOther t Type of Grout <br /> Repair Work Done Type of Pumurface Seal Installed by <br /> Well Destruction ❑ Well Diameter H.P.hPState Work Done g <br /> Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR ADDITION -� <br /> „T U / Lf {No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence / Commercial Other available within 200 feet.) <br /> Number of living units: / Number of bedrooms Z1 <br /> Lot size' i <br /> Character of soil to a depth of 3 'feet: S/91Y c_l d <br /> SEPTIC TANK Water table depth .70 ' <br /> Type/Mfg �,'� -,qV7- Capacity /460'0 61•x( No. Compartments a. <br /> PKG. TREATMENT PLT. ❑ Type/Mfg ;( Ca acit <br /> SEWAGE SYSTEM p y Method of Disposal <br /> DESTRUCTION Distance to nearest: Well Foundation Property Line <br /> f <br /> LEACHING LINE LXNo. & Length of lines A - '/`d' Total length/size f ` <br /> FILTER BED Distance too nearest: Well /o d ` Foundation A S` i <br /> •l Property Line %�S <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS LI Distance t1nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules andiregulations of the San Joaquin Local Health District. 77� i <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 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 st call for all required inspections. Complete drawing on reverse side. <br /> Signed X o <br /> Title; Date: <br /> NT USE ONLY <br /> FOR DEPARTME <br /> Application Accepted by Area [] Stk 466-6781 <br /> Additional Comments: j Lodi 369-3621 <br /> Pit or Grout Inspection by 1 Date Manteca 823-7104 <br /> Final Inspection by' Date —�7-.�� <br /> /� L7 Tracy 835-6385 � <br /> Applicant - Return all copies to: Environmenta ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> I <br /> FBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE <br /> O PERMIT N0. <br /> 7L <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br /> * I <br />