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Ii S P SERVAPPLI.CATION FOR PERMIT <br /> �N­ IcE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 2-53 r0 <br /> X 095,20.5 1601 E. HAZELTON AVE., STO CKTON, CA PERMIT NO. <br /> 'Mh <br /> Telephone (209) 466-6781 <br /> DATE ISSUE4 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application� is hereby made' to the San Joaquin Local Health District for a pernit-tc 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.ti San Joaquin Local Health District. <br /> Job Address , -2-9d,3? /-4 _Z1671�' Subdivision Name <br /> Owner's Name .Address 32cl. _g!Lg� Phone <br /> CpF, <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION L] <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION A N GRICULTURE WELL OTHER WELL PITS/SUMPS <br /> _J <br /> INTENDED USE TYPE OF WELL "--PROBLEM AREA' CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑Open Bottom DManteca Dia, of Well Excavation <br /> 7_1 Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> 17 Public F-1-Other ❑ Delta Type of Casing <br /> Irrigation Approx. Eastern Specifications <br /> ❑Cathodic Protection r.' Depth Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout <br /> ❑Other Surface'-Seal Installed by <br /> Repair Work Done Ej—Type-of-Pump H.P. �"'Sfjie',Work Done <br /> Well Destruction F-1 Well Diameter Sealing <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E) REPAIR/ADDITION [Voe (No septic tank or seepage pit permitted if public sewer is <br /> AW MV available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: -__4 Number of bedrooms Lot size <br /> Character of soil to a depth of 3.feet: Water table depth J <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PUT. Type/Mfg-;1:F_ Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance.�84nea rest:4;4L5;&,�_�_ �,U'ndation Property Line <br /> DESTRUCTION El- . . ,'� <br /> LEACHING LINE No. & Length of lines r Total length/size <br /> FILTER BED stance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ^Depth Si"! Y Number <br /> SUMPS Distance.to nearest: 4;l1&, oundation LT Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be donetin accordance with San Joaquin county <br /> ordinances, state_3aws,,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'tobecome subject to workman's 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'peririt is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant me in tuer <br /> .5 c��for all r ns. Complete drawi q4nC!aZer <br /> sid <br /> Signed A Title: Date: <br /> ONLY <br /> 0 Application Accepted by Area Q: ❑ Stk 466-6781 <br /> Addition.al,Comments. Lodi 369-3621 <br /> Pit or Grout Inspection by Date -e,- - Manteca 823-7104 <br /> Final Inspeffibirf'"ry— Dat Tracy 835-6385 <br /> Applicant - Return all co o; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> AMOUNT REMITTED Y J DATE PERMIT NO. <br /> EE BASE AMOUNT DUE RECEIVED B <br /> FEE <br /> NFO <br /> q 1,9 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />