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APPLICATION.FCR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PET <br />[ F Telephone (209) 466-6781 RMIT NO. <br /> DATE ISSUED <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Comp}ete in Triplicate) <br /> k 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 fpr well/pump <br /> 1 and,the Rules and Re ul ions of he San.Joaquia►Local Health District. <br /> Job Address Subdivision Name 72 <br />' Owner's Name ' Address <br /> Phone <br /> Contractor's Name 1' License No. <br /> Phone <br /> TYLE OF-WELL/PUMP WORK: NEW�WELL WELL REPLACEMENT E] DESTRUCTION <br /> i PUMP^INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER7LINES _ DISPOSAL FLO: PROP.' LINE <br /> FOUNDATION i AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> NT <br /> IENDED USE <br /> � s TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - <br /> Industrial ; ❑ Open Bottom D Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> ❑ Public Other Delta <br /> Irrigation Type of Casing 1 <br /> Approx. Eastern 1 <br /> ❑ Cathodic Protection . epth Specifications O1' <br /> --Dept' ❑Geophysical � _ ' <br /> � t <br /> Type of Grout <br /> F-1Other , ' <br /> � . Surface Seal Installed by r I <br /> Repair Work Done Type of Pum <br /> ❑, YP P H.P. State Work Done <br /> Well Destruction — We11.Diameer <br /> ' Ulww t <br /> -- �.J_ Sealing�Mnaterial (top 50 1) C <br /> Depth Filler Material -(Bel ow-501 <br />_ - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,.ADDITION ❑ (No sept-ic tank or,seepage pit permitted if public sewer is <br /> . <br /> 1 ccr1/rtr, N available within 200 feet.) <br /> Installation will' serve: Residence_ Commercialther <br /> Number of living units: Number ofbedrooms Lot-size <br /> Character of soil to a depth of 3 feet: W ter table depth <br /> SEPTIC TANK Type/Mfg acityr Compartments �- <br /> PKG. TREATMENT PLT, [JType/Mfg Capacity ' Me had of Disposal <br /> SEWAGE SYSTEMC <br /> Distance to nearest: Well Foundation Property Line ' <br /> DESTRUCTION ❑ <br /> LEACHING LINE ❑ No. &y Length of lines ITotal length/size <br /> FILTER BED Distance- o nearest:We *Foundatio + Property.Line F 1 <br /> i <br /> SEEPAGE PITS Cj, • Depth 1 Size Number i ' <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'acco ante with San Joaquin county # <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health,District. j;. I <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 applicant uscall for al aired inspection . Complete drawing onFreverse side.+ .0'* <br /> . - <br /> Signed X Title: 'Date: J <br /> F}R D RT NT USE ONLY <br /> Application Accepted by QF Area �2_-f�a # Stk 466-678 <br /> Additional Comments: , c rw. !'2r [et z15, 1''rtr Lodi 369-3621 <br /> Pit or Grout Inspection by Date L J Manteca 823-7104 <br /> Final Inspection by - Date E Tracy 835-6385 <br /> Replicant - Return all copies to: Errvnmental Health Permit/Services 16 I ze tan Ave., P.O. Box 2009,,-S£k: CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE <br /> INFO <br /> EH 13-24 REV. 10182 <br /> 14-26 �b/�� Cy[_ �i1lJ vw� , <br />