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Fes. _ •� �Y <br /> APPLICATIOiN' FOR PERM:? <br /> r <br /> SAN JOA%iN LOCAL Hc4LTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> % DATE ISSUED <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 Jr compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of theJoao "n Loc l Health District. <br /> Job Address : t �i� 1 Subdivision Name LQLIl r <br /> Owner's Name 1� r ress T f� � Phone <br /> Contractor's Name n j License No, Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION l'— SYSTEM REPAIR L7 OTHER <br /> DISTANCE TO NEAREST:" SEPTIC TANK _/J00 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> { FOUNDRTION AGRICULTURE WELL JV <br /> dolk OTHER. WELL PITS/SUMPS ZLI — 1 <br /> INTENDED USE TYPE OF WELL PR03LEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom �] Manteca Dia. of Well Excavation <br /> Domestic/Private ( Gravel Pack Tracy Dia. of Well Casing � / �j G Y1 <br /> �] Public., Lj Other elta Type of Casing <br /> V Irrigation Approx.V Eastern <br /> Depth <br /> Specifications � <br /> [ eCathodic Protection p = i <br /> �a Depth of Grout Seal <br /> Geophysical'` ` .� " <br /> L)Other F "Type of Grout <br /> Surface Seal Installed by M W6 <br /> 'Repair Work Done ❑ Type of Pump HIP. Z State Work Done 10e.5:P1' <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is } <br /> � available within 200 feet.) F. <br /> lhstalla�L�i"4n wili serve: Residence _ Commercial _ Other C, 4 <br /> Number of livin its Number of bedrooms Lot size G <br /> Character of soil to a 3 feet:" Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ttt333 <br /> PKG. TREATMENT PLT. �� Type/Mfg Capacity Method of Disposal rr` <br /> SFWAGE- SYSTEM Distance to nearest: Well Founda i Property Line (� 1 <br /> DESTRUCTION ❑ - <br /> LEACHING LINE U . No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS, Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <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 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 /> 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 applican u t for a 1 required inspections. Complete dra i reve se s'd <br /> Signed X � '^'"'`"' XZ <br /> Title: � ry Date: / <br /> PRRTM T USE ONLY q !S.-0 <br /> Application Acceed Area Stk 466-67 <br /> Additional omments: Lodi 369-3621 <br /> 6 <br /> Pit orro Inspection by Date / (>hr Manteca 823-7104 <br /> Final Inspection by Date �' Tracy 835-6385 <br /> Applicant - Return all copies o: Environmental 4ealth Permit/Services 16,01 E. Hazelton ! !, P.O. Box 2009, Stk., CA 95201 <br /> FEEBRSE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> t o 5- e " VI 7-/ S-7-8-3 <br /> 8 I <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />