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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT T 14 63� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. `t <br /> Telephone (209) 466-6781 <br /> a PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED 3 <br /> t <br /> (Complete in Triplicate) r <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 the San Joaquin Local Hea 'V <br /> Job Address Subdivisi <br /> on� mGe � <br /> . <br /> Owner's Name Address 3 Phone <br /> Contractor's Name <br /> License No. a SJ Phone 3&4- �/ <br /> _9 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION, <br /> y PUMP INSTALLATIONf( SYSTEM REPAIR OTHER [:3 f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD./,gO z PROP. LINE %q <br /> FQUNpATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fD Industrial Open,Bottom E] Manteca 'Dia:-of Well Excavation . <br /> Domestic/Private-.r.. Gravel, Pack>�D ^� <br /> Tracy -;- Dia:,of'Well Casing's <br /> L] Public Other ❑ Delta <br /> Irrigation 4 Type of Casing n e-e l <br /> 719 ��-� Approx. � Eastern =-�.- - --� <br /> Depth <br /> Specifications { <br /> Cathodic Protection p Depth of Grout Seal <br /> Geophysical {� <br /> .0 Other, Type of Grout f , <br /> Surface Seal Installed by A-Y kpjh��Q <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction We]1 Diameter !f '.Sealing Material (to50'}� i4 Y <br /> C��--fie <br /> Depth �-y; s► :_ ' -Fil,ler*Mater ia1 (Below 50') '*'SQ�+dQ� %b <br /> ~TYPE OF SEPTIC WORK: NEWtINSTALLATION REPAIR),ADDITION ❑ (No !sept c.,tank..or,seepagelpit permitted if public sewer is <br /> -.. 11 <br /> k; 11 .. ,�... available within 200 feet.) <br /> Installation will serve: Residence Commercials ;Other__ •_ { <br /> Number of living units: 'I - - (J� <br /> " """-"'Number of.hedrooms Lot size +,. <br /> ` Character of soil to a depth of 3 feet: "4 Water table depth <br /> SEPTIC TANK IT e Mf p <br /> � yp / g � Capacity T No, Compartments <br /> PKG. .TREATMENT PLT. U Type/Mfg . Capacitty Method of Disposal <br /> + 'SEWAGE SYSTEM Distance to nearest: Wel l"- "�Foundation'+� Property Line <br /> DESTRUCTION f <br /> ,LEACHING LINE �} INo, & Length of lines Total length/size <br /> FILTER BED iDistance to nearest: Well Foundation :i. Property Line <br /> SEEPAGE PITS [j 'Depth Size Number <br /> SUMPS ��, -Distance to nearest: Well Foundation * Property Line <br /> .DISPOSAL PONDS <br /> t <br /> 1 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 workmant compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing: "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 applicant t call for all required inspections, Complete drawing on reverse 'side. A` <br /> y. # Signed X � � - ► a Title: IsG C� S -- Date: g il <br /> ` FOR DEPA MENT USE ONLY,/ <br /> r Application Accepted byAl Area . Stk 466-6781 <br /> i <br />,e # Additional Comments: 1 1:_,�todi 369-3621 <br /> Pit orGr`t Inspection by Date �,z y U Manteca 823-7104 r <br /> Final Inspection by Date Tracy Tracy 835-6385 <br /> Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton A've„ P.O. Box 2004, Stk., CA 95201 <br /> s <br /> FEESASE AMOUNT'—DUE'""7. ""'AMOUNT REMITTED RECEIVED BY "'` DATE PERMIT NO. <br /> INFO <br /> Z;izz, p� <br /> EH 13-24 REV. 10/82 10/82 50C <br /> 14-26 <br />