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.n <br /> APPLICATION FOR PERMIT <br /> 4 <br /> $� SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> M Telephone (209) 466-6781 <br /> DATE ISSUED s <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; <br /> (Complete in Triplicate) <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,.Ruies and Regulations of the San Joaquin Local Health District. <br /> t Job Address /6 Subdivision Name <br /> Owner's Name /V�lc/.4�/Q0," - Addres Phone <br /> Contractor's Name <br /> _A�L.ryLGc � License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT T <br /> � [] � DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial ❑ Open Bottom Manteca Dia. of Well Excavation <br /> Lj Domestic/Private n Gravel Park ❑ Tracy Dia, of Well Casing <br /> m Public ❑ Other Delta <br /> Irrigation Type of Casing <br /> { V g Approx. Eastern <br /> , 4 F-1Cathodi�Protettion � Depth Specifications <br /> Geophysical <br /> Depth of Grout Seal <br /> 17 Other <br /> Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑. Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> I <br /> -''-r-�­TYPE OF-,SEPTICWORK NEW-3NSTAL-t STALL-ATA J-:-FREP.AIR/ADDI-TlON=- <br /> �' Uo :t <br /> eptacank or:seepage. pat permitted if public sewer is <br /> . <br /> s ', vaihab•he-wthin�2A0 feet. <br /> Installation will r serve: Residence , Commercial X( Other ; <br /> Number of living units: Number of bedrooms Lot size z�,d Y�/O � T <br /> Character of soil to a depth of.3 feet: Water table depth r z <br /> SEPTIC TANKType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLf. ❑ Type/Mfg Capacity Method of Disposal <br /> 1 SEWAGE SYSTEM Distance to nearest: Well '. Foundation Property Line "_ Y <br /> ! DESTRUCTION ❑ <br /> LEACHING LINE y No. & Length- of lines Total length/size <br /> I FILTER BED E Distance to nearest: Well Foundation - Property Line. <br /> SEEPAGE PITS Depth Size , Number <br /> i SUMPS L� Distance to .nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ` i. X <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 i,,state-Paws;~andErules 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 /> perr�itz,is;'i.ssued-,, I slia,l.l not employ any person in such manner as=to become sutiject to",workman$ compensation laws of California." _ <br /> Contractor's hiring'or sub-contracting signature certifies the followings.'"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 /> � f <br /> I <br /> The''appli•cant must calll.' ,a• required inspections. Complete drawing on reverse side. ..d. <br /> Signed: X <br /> �. ry (IYYIARTMLNT USE'ONL.Y <br /> Applicationiccepted by Ar <br /> eak�- { <br /> St ms"4'66 6781 <br /> Additional Comments: _ r, _/ „ 0 Lodi 369'3621 <br /> P. x v <br /> it or Grout Ins ection`b Date <br /> _ P y ti at 1 Manteca 823=7104 <br /> Final Inspection by ", " ""'" Date ❑:=Tracy 835=6385. = ;, <br /> Applicant - Return al�I copies to.Envird menta ealth Pe mit/Services 1601 E.,Hazelton Ave.,--P:0. Box 2009,! Stk., CA"-95201 <br /> i <br /> FEE BASE -'AAOUNT'�60E/' AMOUNT REMITTED RECEIVED BY DATE PERMIT,NO. <br /> NFO <br /> v T EH 13-24 REV. I0/82 � " - �� 10/82 500 � <br /> 14-26 <br /> }" -- <br />