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APPLICATION FOR'OPERX; <br /> SAN JOAQU0,' LOCAL HEALTH :)7STRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781. <br /> DATE ISSUED <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 permit to construct and/or install the work herein <br /> .described. This application is made in compliance with Sari Joaquin County Ordinance No;. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job'Address I Z 4_!5 67-t4V r _<7-k_A_� Subdivision Name <br /> Owner's Name V i DD L c AddressPhne�Wr <br /> Contractor's Name -A0A,1S License No, Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT LI] DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR Lj OTHER D <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP'-.17NE <br /> FOUNDATION AGRICULTURE WELL OTHER ER WELL PITS/SUMPS f. <br /> 'IIV-TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ej <br /> Industrial <br /> F] Open Bottom Manteca Dia. of Well Excavation <br /> F-1 Domestic/Private 7 Gravel Pack Tracy Dia. of Well Casing <br /> 17 Public [I Other F-] Delta Type of Casing <br /> FlIrrigation Approx, E] Eastern Specifications <br /> Cathodic Protection 'Depth <br /> GeophysicalDepth of Grout Seal <br /> 0,j Type of'Gr`6ut <br /> L)Other <br /> SurfacekS&I Ins <br /> Repair Work Done L1 Type of Pump H,P, State Wor`k'Done <br /> Well Destruction [_� Well Diameter Sealing Material (top 50') <br /> Depth Filler Material .(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Othe'r <br /> Number of living units: <br /> Number of bedrooms 7— Lot size YJ D $4-1 2-;V- � <br /> Character of soil to a depth of 3 feet: /992� Water table depth <br /> ity/- No. Compartments <br /> SEPTIC TANK E: Type/Mfg Cap9c, , <br /> PKG. TREATMENT PLT. Type/Mfg J Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines0 Totall.length/size <br /> Z. <br /> FILTER BED ❑ Distance to nearest:, Well Fourdatib`n­ Property Line <br /> SEEPAGE PITS r_1 Depth /17. size V J(ff 'Number_ <br /> SUMPS Distance to nearest: Well Fourdat.ion Property Line <br /> DISPOSAL PONDS If.I hereby certify that I have prepared this application and that the work will/be done in accordance with San Joaquin county <br /> - <br /> ordinances, state laws, and rules and regulations of the San'Joaquin Loc&I'llealth District. <br /> Home owner or.1 i e7sed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> 1, <br /> permiti shall not employ any person in such manner as to become subject to workrnan$ compensation laws of California." <br /> Contractlorts h ing or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> m <br /> this perm t i i sued, I hall emplo pers. s subject to rkman's compensation laws of 'California." <br /> Y, laws <br /> "t <br /> s <br /> g 0 r, <br /> s <br /> �n e side., <br /> Comp <br /> li t % I - <br /> The appli st call r all in ns Comp e g on reverse side. <br /> T tl-e-:- <br /> Signe0c 0- i Date: <br /> t PA NT USE ONLY <br /> ^. a tk 4:::4�6 6-�67 8 1L_:_D <br /> • Application Accept by Are C?r <br /> - &/, AAOVZ* Lo d i 369-3621 <br /> Moff: Additional Comments: eL_ <br /> -Ork avolp - <br /> or Grout Inspection by Dao"-LZ-- Manteca 823-7104 1 <br /> Final Inspection by Date 0— Lj Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNTDUE AMOUNT REMITTED RECEIVED BY L DATE PERMIT NO. <br /> 10Y� o-0 <br /> — <br /> LH 13-24 REV. 10182 <br /> 14-26 514w* 71k 1;G <br /> _f 49, —5 oFo <br />