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APPLICATION FOR'PERMIT <br /> SAN JOAQUIN'LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON. CA .. PERMIT NO. <br /> Telephone (209) 466-6781 <br /> , <br /> ' PERMIT EXPIRES'l'YEAR FROM DATE ISSUED 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'San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and a UI ns'of the San Jo in Lo aI Health District. �� f <br /> Job Address Subdivision flame <br /> Owner's Name / L'x 6 Address Phone <br /> ' <br /> Contractors Name 1 1 *Z„ License No.*E •�r��.�.C,,C-f_ rad '�'!S Phone <br /> j TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [D <br /> DISTANCE TO NEAREST: SEPTIC TANK�1 ..; SEWER LINES DISPOSAL FLO. PROP. LINE - <br /> 'il. FOUNDATION 'ti tAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F 1 O <br /> Indoatirial .._ -. Bottom pen ,.,.._E ..Manteca -..; _.� -...°.. <br /> Dia. of Well Excavation <br /> Dom"stic/Private <br /> L.1 [J Gravel :Pack.. ❑Tracy­ ___Dia, oLWell_Casing_ - <br /> Public F-10ther Del to O <br /> Type,of Casing <br /> Irri, ation • <br /> ` (J 9 Approx. []Eastern <br /> �i ti { Specifications <br /> ❑Cathodic Protection i Depth y . <br /> (]Geophysical Depth of•Grout Seal ? 1 <br /> LD Other i Type of Grout i g <br /> �. _ Surface Seal Installed by <br /> y Repair Work Done �] Type of'Pump 4 H.P. ;, State Work Done <br /> ,. <br /> Well Destruction Cl Wel] DiameReri Sealing Material (top-50'}_� <br /> Depth Filler Material (Below 50') f <br /> 1 s <br /> 'TYPE O�'SEPTIC'WORK: NEW INSTALLATION REPAIRYAODFTION- NoTsapt-17-tank-orrsseepage-pelt-permitted-;,i;f.'public sewer-is—u— Ji�-•-- <br /> available within 200 feet'.) <br /> Installation will serve: Residence L Commercial 0 er I r <br /> Number of living units: _ 'Numb&-B?bedrooms` Lot Size -A C-- <br /> Character <br /> -Character of soil to a depth of 3 feet: Water table depth_ <br /> �-✓ SEPTIC TANK Type/Mfg. '� �{}%' ^-- ^�^° C,l:atity -No- Compart s._ -2 i <br /> PKG. TREATMENT PLT. 0 TypeMfg( � .� tS' •.Capacity Method of Disposal <br /> SEWAGE SYSTEM Distancelto nearest: Well Foundation #P-1-Property Lane <br /> DESTRUCTION r ❑ 1 <br /> LEACHING LINE . No. & Length of lines Total length/sjze. <br /> FILTER:BED Distance'to nearest: Well Foundation Aropgrty Line tl i <br /> i SEEPAGE PITS i i Depth Size ' Number w= <br /> SUMPS i U Oistance'to nearest: Well Foundation Pr3perty Line <br /> 'f 4 1 <br /> DISPOSA!L PONDS <br /> i r <br /> I hereby certifylthat I have prepared this application and that the work will be done it accordance with San Joaquin county <br /> I ordinances, state laws, and rules .and.,r_egul.a.tions_of-the.San-Joaquin.L-gcal--Hea]•th^•District:. <br /> l Hone 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'il shall not employ any person in such manner as to become subject to worldnans compensation laws of'California." <br /> ct <br /> Contraor's hiring or sub-contracting signature certifies the foiiowihq-N"I_certify that in the performance of the r�rk for which <br /> this permit is issued, I shalll employ persons subject to workman's compensation laws of California." f <br /> The applicant must call or•.41*1 requ;jpd inspections. Complete drawing on reverse side. i gr <br /> Signed XsTitle: Date: <br /> .,..,FOR.DEPARTMENT,USE.ONLY_ <br /> Application Accepted by i Area Stk 466-6781 E <br /> Additional Co"Wnts: ` _ ❑ Lodi 369-3621 ; <br /> Pit or Grout'Inspectionx y Date ElManteca 823-7104 <br /> Date <br /> a <br /> Final Inspection by <br /> 4 � ❑ Tracy 835-6385 F. <br /> Applicant - Return all copies to: EnvirowfZtaTHealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AM06NT DUE �AMOUNT REMITTED . RECEIVED BY DATE PERMIT N0. I} 1 <br /> INFO6, •r ______,, <br /> 0o S "57t 3 :r <br /> EH 13.24 a.R6V.<10/82 10782­500­- <br /> 24-26 <br /> 0%82"500""', -14-26 <br />