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APPLICATION FOR PERMIT <br /> :i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED I� <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 with San Joaquin County Ordinance No. 549 for sewage or No. IB62 for well/pump <br /> and the:Rules and Regulations of the San Joaquin local Health District. �Y�A ��_ I1� <br /> Job Address P , Subdivision Name tr l <br /> T Owner's Name $/pys/ Vpa�G��, I['�y�/irI- Address 9 hone 9 •-0 <br /> Contractor's Name- License No. ���L�� - _ _ Phone <br /> s _ 1� <br /> TYPE OF WELL/PUMP WORK: NEW WELL I] WELL REPLACEMENT DESTRUCTION ) <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Open Bottom F�Manteca Dia. of Well Excavation <br /> -' Domestic/Private <br /> -- � F-1 Gravel Pack L]Tracy Dia. of Well Casing <br /> 1 Public FJ Other 0 Delta <br /> Type of Casing <br /> U Irrigation Approx. 0 Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> EQ Geophysical <br /> Type of Grout <br /> f 1---1 Other Surface Seal.Installed by <br /> €a} Repair Work Done Type of Pump H.P. State Work Done <br /> 1 Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> M TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> :Installation will serve: Residence Commercial _ Other <br /> 'Number of living units: �_ Number of bedrooms ` Lot size -wo Y QL.1- 1 <br /> 'Character of soil to a depth of 3 feet: ... E-C^tA Water table depth <br /> SEPTIC TANK Type/Mfg apacity /,$g!�kb�� No. Compartments <br /> PKG. TREATMENT PLT. U Type/Mfg Capacity Method-of Disposal <br /> - Distance to nearest: Well /4004'f-Foundation 7-p Property Line (dQ <br /> I LEACHING LINE No. & Length of lines 3 ^- !3 Total length/size <br /> FILTER BED Distance to nearest: Well M 64- Foundation 3 0" Property Line / <br /> SEEPAGE PITS Depth Z� Size �k -2-' S Number 3 � <br /> SUMPS „ LJ Distance to nearest: Wellf"r-Foundation 7d Property Line <br /> w DISPOSAL PONDS D <br /> ' I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> a Home owner or licensed agent's signature certifies the fallowing: "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 ing or sub-contracting si Store certifies the following: "I certify that in the performance of the work for which <br /> this .permit s s ed, I sha employ pe ons subject to workman's compensation laws of California." <br /> The appli nt 11 fo all req a inspections. Cpmple dr on reverse side. <br /> Signed Title: Date: <br /> . FOR P NT USE ONLY <br /> 4 Application Accepted by Area Stk 465-6781 <br /> y Additional Comments: Ej Lodi 369-3621 <br /> Pit or Gveut-Inspection by' Date f- S-- V El Manteca 823-7104 <br /> Final Inspection by ?iz - Date K 0 Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Pee/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IEEO BASE AMOUNT. DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> ,... Q c7 Q <br /> EH 13-24 REV. 10/82 10/82 500 <br />