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r ` <br /> APPLICATION FOR PERM--T <br /> SAN JOACUI-N LOCAL 'HEALTH DISTRICT <br /> -- <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> � <br /> PERMIT EXPIRES 1.Y ERRDATE 1ssuED 7 <br /> . FROM DATE ISSUED _ � - <br /> k (Complete in Triplicate) <br /> y <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 tFe�San Joaquin Local Health District. <br /> Job Address Y '7/,-0 ` 1V6j -111XAVjleJ Subdivision Name <br /> .,Owner's Name Address' it/!igL��+�avDJE iD Phone <br /> Contractor's Name -A. License No. ;�� �� Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FCD:^ w" "` PROP: LINE r <br /> FOUNDATION ! AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s <br /> ❑ Industrial U Open Bottom © Manteca Dia. of Well Excavation <br /> U Domestic/Private F-1 Gravel Pack ❑ Tracy Dia, of well Casing <br /> 1­1Public [j Other! ❑ Delta Type of Casing <br /> V Irrigation Approx. ' Eastern <br /> F-1Cathgdic Protection Depth ` • Specifications ; <br /> Depth of Grout Seal <br /> ❑Geophysical f <br /> Other f Type of Grout <br /> Surface Seal Installed•by, k , <br /> s <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done .ti44: <br /> Well Destruction U .Well Diameter Sealing Material (top 50') <br /> Depth j Filler Material (Below 50') i <br /> j O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION ;< (No septic tank or seepage pit permitted if public sewer is }, <br /> 4 available within 200 feet.) ` <br /> Installation will serve: Residence Commercial _ Other <br /> Number of living units: /�-- Number of bedrooms Lot size I <br /> Character of soil to a depth of 3 feet: /✓t Water table depth <br /> r.. .... _._.�-. <br /> fSEPT]C TANK ❑j Type/Mfg �~ ' Capacity NoCompartments 4 <br /> PKG, TREATMENT PLT. ❑ IType/Mfg - Capacity -. Method of Disposal a• <. <br /> SEWAGE SYSTEM ` Distance to-neares-t:`s.fW_elI Foundation -.+ "-Property Line <br /> DESTRUCTION d i <br /> LEACHING LINE ❑ No..& Length of lines1'7 Total length/size i <br /> FILTER BED Distance to nearest: . Well Foundation i L�yT Property Line <br /> 3 <br /> SEEPAGE PITS ❑ =.Depth�. �T,TT.�.._—Size �, W Number _ I <br /> SUMPS [71 Distance to nearest:'� Well oi_Foundation-- ,. Pr-operLy Line <br /> '%DISPOSAL PONDS ❑ ��c:ra` °°'^�-*- ,�, ,.�. � t <br /> ' I hereby certify that I have prepad t ih`�s plica o.:andithat the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules andregult, a`�ps of theSan 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 issued, I shall not erpl_oy any person'-im such mang6r as:to became subject to workmans 05) pensation laws of Galiforn,ta " <br /> Contractor's hiring or sub-contraotinq sigiiatu-re,certifies"t4ie fallowing: "I certify that in the, performance of the work for which <br /> this permit is issued, I SNR,11 �mploy persons subject to workman's compensation laws of California." f <br /> The applicant must c 1 fo ,ell re uired"inspec,tions. Complete drawing on reverse side. <br /> Signed X >�� � ��. � _. �_ y! Title: Date: <br /> �` � I c '* „OR DEPARTMENT USE ONLY � <br /> Application-Accepted by t Area ❑ Stk 466-6781 <br /> AdditionalfComments:' v ___ R [] Lodi 369-3621 <br /> ¢ _ <br /> Pit or Grdut lnspectian,by. a P Date : . Manteca 823-7104 <br /> I , <br /> Final Inspection by!? Date # ❑ Tracy 835-6385 <br /> Applicant - Return all copi• s to: Environmental Health Permit/Services 15011 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> u FEE - 'SAS'E A OUHTOUE#. ,.�.-. .RMOl11VT REMITT.E)}' RECEIVED BY` DATE _ PERMIT NO <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 ' <br /> 14-25 ' <br />