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± � APPLICATION FOR PERMIT <br /> SAN JOA U <br /> ° R IN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE,, STOCKTON, CA p <br /> Telephone (209} 466-678, a r �� <br /> PERMIT N0. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> DATE ISSUED <br /> (Compiete in Triplicate} <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct an <br /> described. This hereby <br /> ade is made in compliance with San Joaquin Count <br /> and the Rules and R ations of the San Joaqui Local H alt District, drew install the work herein <br /> { y Ordinance No. 549 for seway a or No. <br /> Job Address Q/ / f fit f r <br /> ' l Weil/pump <br /> Owner's Name Subdivision Name s:V g62—SL'/? <br /> G Contractor's Name 0I ddress <br /> 111f License No, r ne <br /> h TYPE OF WELL/PUMP WORK: Phone <br /> f NEW WELL. WELL REPLACEMENT <br /> DISTANCE TO NEAREST; SEPTPCMP INSZALLATIOi ❑ SYSTEM REPAIR DESTRUCTION❑ <br /> SEWER LINES C� <br /> FOUNDATION AGRICULTURE WELL DISPOSAL FLD, <br /> PROP. LINE ���_ <br /> INTENy pED USE OTHER WELL <br /> TYPE,^ OF WELL PR081EM AREA ��_ PITS/Si1MPs ^ <br /> 1n5y trial �— CONSTRUCTION SPECIFICATIONS <br /> mestic/Private ❑ Open m ❑Manteca <br /> vel Pack Ilia. of Well Excavation <br /> Public ❑ Tracy <br /> Irrigation �_!Other ❑ Delta Dia, of Well Casing S i <br /> LJ❑ <br /> Cathodic protectiApprox. E] Eastern Type of Casing <br /> Geophysical on Depth S <br /> Specifications { <br /> ❑Other Depth of Grout Seal <br /> Type of Grout <br /> Repair Work Done ❑ Type of Pump Surface Sea] Installed by 4 <br /> Well Destruction 14. <br /> P. <br /> State Work Done f <br /> UI Well Diameter-`�"_ Sealing Material <br /> Depth (top 50 1) <br /> Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK:` NEW INSTALLATION ❑ REPAIR/ADDITION` + <br /> Installation will serve: Residence U (No septic tank or seepage pit permitted if public sewer is <br /> Number of living units: _ Commercial' _ Other available within 200 feet.) � <br /> Character of soil to a depth of 3Nfeetr of bedrooms <br /> ___�_ Lot size <br /> SEPTIC TANK 0 Type/Mfg Water table depth } <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity • No, Compartments <br /> Distance to nearest: WellCapacity Method of Disposal <br /> FoundationPr <br /> � r <br /> operty Line <br /> LEACHING LINE D No, & Length of lines ~- <br /> FILTER BED ❑ Total length/size r' f <br /> Distance to nearest: Weil Foundation ,e. <br /> Property Line <br /> SEEPAGE PITS ` <br /> Depth Size <br /> SUMPS �'"�- Number <br /> DISPOSAL PONDS <br /> U Distance to nearest: Well Foundation <br /> ED Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county E <br /> ordinances, state Taws, and rules and regulations of the San Joaquin Local Health District, <br /> Home owner ss 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 t compensation laws of California." <br /> Contractor's hirin -contracting signature certifies the following; "I certify that in the performance of the work for which <br /> this permit i iss d, s empl y persons subject to workman's compensation laws of Cal'farnia," <br /> The applic st re i d inspections. Complete draw <br /> Signed K tY�ev i e, <br /> Title: <br /> Da <br /> Application Accepted by <br /> OR DEPARTMENT USE ONLY pydpe� e <br /> Additional Comments: Area Stk 466-67 <br /> Pit or Grout Inspection by 7` ❑ Lodi 369-362.1 `�'�""'"• <br /> Fina] Inspection by Date Manteca 823-7104 G(� <br /> Date <br /> Applicant - Return all copies to; Environmental Health Permit/Services 1601 E, Hazelton Ave,, P❑.O,TracyBox 2D0835-638, CA 95201 <br /> FEE BASE AMOUNT DUE <br /> INFO AMOUNT REMITTED RECEIVED B92B?P <br /> D ERMIT N0. <br /> 419 <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br />