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- L APPLICATION FOR'DERMIT
<br /> .. w
<br /> -`•-:.- ACTH DISTRICT 1 a
<br /> " SAN JOAQL„iN IOCRL.HE. "� PERMIT NO- �•-• r Fti '
<br /> t�bZx ..NAZELIQ.4 AVE., STDCKTON, CAv e r
<br /> .'1601 EI TelffphoAe<(Z09j,Afi6-6781 ^,. •� .��" I . ' DATE ISiU.6'..�s' t �.
<br /> ✓ }, "t
<br /> / PERMIT E%P IRES'1 YEAR FROM DATE ISSUED
<br /> (Complete in Tr;placate) y St: _ e
<br /> ^w
<br /> ��' lication is maSanJ compliance with�San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/Pump
<br /> ADpl icati on is hereby made to the San Joaquin:Local health District for permit to coristruct'adE/or install the work erein
<br /> de�in
<br /> -+r:�escribed. Thi s'app
<br /> nd,the,Rules and Regul atlO]5.of the n joaqu�n Local.Heal Subd;vth ision Name phone,,2•
<br /> lee
<br /> Job Address %me _ . Address / l Phone
<br /> z
<br /> Owner's Name � ! � � License No.
<br /> Contractor's Name DESTRUCTION Fl `
<br /> 'f NEW WELL ❑
<br /> WELL-REPLACEMENT ❑
<br /> OTHER ❑ '`'�`
<br /> TYPE OF OF WEA SYSTEM'REPAIR ❑ �pROP. LINE
<br /> �, PUMP'{�NSTALLATION ❑ SEWER LINES DISPOSAL FFLO. ,LAv «--
<br /> 47IC TANK �— § B7HER'hiEL%L
<br /> PIIS/SUMPS'
<br /> ,^`-• DISTANCES
<br /> FOUNOAT YOAGRICULTURE WELL
<br /> .v B `-s' °•
<br /> ! CONSTRUCTION SPELT FICATIONS �
<br /> TYPE OF WELL
<br /> PROBLEM
<br /> iy.r,ry INTENDED_USE ,+' •,,,� . Manteca
<br /> Dia. of We71 Excavation
<br /> .r" I in in
<br /> V Open Bottom ❑ Dia. of Well Casing
<br /> ❑' F in Gravel Pack (]Trady .r
<br /> u.Dome9tic/Private ,O pelta, Type of Casing -
<br /> ' ❑Public C1 Others
<br /> ✓,,._ ^'
<br /> Approx.-
<br /> Irrigation
<br /> `� ❑Eastern, 'Stfecifications
<br /> Lj Irrigation ' nep3«h Depth of Grout Seal �.-.
<br /> '❑Cathodic protection Type of`Grout
<br /> (❑'Geophyscal`;, a+'t Surface Seal Installed by ------
<br /> Other -
<br /> s + �-, ^• H.P. _�—State'Work Done
<br /> • " .f-� Type Of Pump"
<br /> v RepairtNorY;9one Lam. YP '-" Sealing Material (top 50') 5
<br /> !` Well_Diameter_
<br /> a Wel l,"DXtruction ❑ ..---% Filler Material (Below 50')
<br /> �,.._ Depth,
<br /> _ No septic tank or seepage.pit permitted if public sewer is
<br /> v ._ - . +..,:r. --•a0ail"IIb,e-witnirt200:fEet.)
<br /> WOR. .
<br /> TYPE OF'SEPTIC�WORK: NEW It�S7ALLAT�ION REP,0.1R/ADDIT ION L.� (
<br /> ! ,a Other
<br /> _r Commeia, -_ —�
<br /> iiv
<br /> (nstai'tation'wtlI serve: kasi den Nu er of bedrooms y Lot size �� rte`
<br /> Number of living units: .- Water table depth /�6.T--'
<br /> - �-a✓ > No. Compartments
<br /> Character of soil.to a depth of 3 feet: ; Capacity /��
<br /> ^.,•tr SEP71C TANK / d'
<br /> -,Type/Mfg
<br /> ` CepacItY Methbd�of Disposal
<br /> Type/klfg_ Foundation property Line
<br /> PKG. TREATMENT PLT. ❑
<br /> SEWAGE SYSTEM ❑ Di siranci?arest: Weil /d1 :..;
<br /> DESTRUCTION � � y '\ Total length/size .
<br /> LEACHING-LINES No. S,!;^/!9Lh .�ines ouno"n: to` Property Line
<br /> sem.
<br /> f 6lstan6e to nearestWe
<br /> i Number \ —
<br /> Depth 2$ Size. ProaertY Line
<br /> SEEPAGE PITS oundation 1&
<br /> x Distance to nearest: Well SO , ,;, ,•„-.�
<br /> A ..SUMPS L-1
<br /> DISPOSAL PONDS ❑
<br /> •7 that ;n the performance of the work for which this
<br /> and rules and regulations of the San Joaquin Local Health District.
<br /> 1 hereby certify 7that have prepared this application and that the work will be done in accordance with San Joaquin county
<br /> ordinances, state laws,age signature certifies the following: "1 certify rf-0rmance-Cf the-w°rk,for which
<br /> 4 Home owner or licensed a9 person in such manner as to become;s`ert+ifytthatr the-per laws of California.
<br /> �� permit is issued, 1 shall not employ a^sipna- le-cert-i'f+es-thr'4oaiowingnsation laws of California."
<br /> . OOtrt+,actot.•s-nirtng-or-subhcontracting' 9 reverse side. -ai/ C
<br /> thts permit is issued, I shall enPldY persons subject to workman's win� pate:
<br /> �. The applicant must call fp, ell required i^sPOCti' Complete drawin
<br /> _Signed X__ ❑ 466-b781
<br /> F ARTMENT USE ONL prQB Stk
<br /> n / �odi 369-3621
<br /> ppplacption Accepted by —�-t— ❑ Manteca 823-7104
<br /> .,.,• A itionaI Comments: pate ❑ Tracy 835-6385
<br /> or Grout Inspection by - pate
<br /> ,yam, e. p•0• Box 2009, Stk., CA 95201
<br /> ' Final Inspection by
<br /> r
<br /> •i Applicant - Return all copies to: Environmental Rea th�Permit/Services lbdl E. aze DATE PERMIT N0.
<br /> i RECEIVED BY
<br /> AMOUNT DUE AMOUNT REMITTED
<br /> 7 FEE l BASE
<br /> INFO 11 ij l S 10/82 500
<br /> • EH 13-24 REV. 10/82
<br /> 14-26
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