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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCA. HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6791 , <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 in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and,the Rules. nd Regul'at' ns of the San Joacuin Local Health District. <br /> ,lob Address 0.1 is ).SN 12'h' +D Subdivision Name <br /> Owner's Name Q AJ C/ <br /> AP AMq d Address Phone <br /> Contractor's Name License No. 2�1 3°�1 Phone Vz 3•G 5 Y <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER Lf <br /> #DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' <br /> INTENDED USE l <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J J Industrial [I Open Bottom [] Manteca Dia. of Well Excavation <br /> r U Domestic/Private ❑ Gravel Pack ❑Tracy i Dia, of Well Casing : r <br /> 1-1 Public CJ Other ❑ Delta <br /> Type of Casing <br /> f Lj Irrigation Approx. Eastern Specifications <br /> �-Cathodic Protection Depth ; <br /> Depth-of­Grout Seal <br /> tt17 Geophysical IF <br /> f Type of GrouF <br /> L1 Other .� <br /> Surface Seal Installed by <br /> 'Repair Work Type of Pump H.P. 1 State Work Dane r <br /> 1 <br /> Well Destruction U' Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') o <br /> � F <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AD'ITION J (No septic tank or seepage pit permitted if public sewer is <br /> x available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other <br /> Number of living units: -j— N Number <br /> of bedr oms 3 -_ Lot size 75 —)-2'J f �� <br /> r Character of sail to a depth of 3 fee'* Other,�n v pti/ Water table`iepth 2+ E <br /> SEPTIC TANK Type/Mfg CAST Capacity O= �; o. Com'pa�r"t�ments; <br /> _12U <br /> PKG. TREATMENT PLT. Type/Mfg Capacity-^" ^�"" Method of Disposal . ; <br /> SEWAGE SYSTEMDistance to.nearest: We11..-'\.. ,Foundation' :Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. &'Length of lines Total length/size ° <br /> s �r <br /> FILTER BED 0,D istance to nearest�� Well - Foundation Property Line <br /> SEEPAGE PITS k0o, Depth _qg size YK 3.2 Number <br /> SUMPS L Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL'-PONDS—•- ; <br /> I I hereby certify that"`I'have prepared `this application and'that the work will be done in accordance with San Joaquin county Q <br /> ordinances state laws, and rules and regulations of the San,Joaquin Local Health District. -1' 1 <br /> Home ownerior licensed agent's,,signature certifies the following: "I certify that in the performance of the work for which this <br /> permit his issued, I shall not,employ,any person iiaiTO 'riei'.as to become subject to worknang compensation laws of California." <br /> Contractors; hiring or sub-contra <br /> ,:in signature. tifies the following; "I certify that in the performance of the work for which <br /> this'permit {is issued, I shall a loy persons.s* ect to,workman's compensation laws of California." <br /> The app`Iica l call r all rd'inspectlon, Complete drawing on reverse side, e• <br /> Signed X Title: : J CR— Date <br /> t I REART4NT USE ONLY �'" <br /> i IApplicat7_onYA'cce�tedyby"' _ "� Area Q� Q Stk 466-6781 <br /> IA. i ona C is . 2,� 7 -yl- E0 evu0. C] Lodi `369-3621 <br /> P' eft a e ���-7 Manteca-823-7104 <br /> Fin-al In pectior by •1 = fi7^�-�- Date ��p 7 L Tracy 835-6385 j <br /> ,,.Applycant._::. ,Return„a-1,1_co•pies to: `Egironmertal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 <br /> FEE I BASE AMOUNT DUE AMOUNT REMITTED 'RFCFTVED BY DATE PERMIT NO. <br /> -_ "1 NFO' - — - 2--�-- - <br /> EH 13-24 REV. 101P'210/82 500 <br /> 14 126 <br />