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' S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQU'iN LOCAL HEALTH DISTRICT 73 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 4.66-6781 ! <br /> I DATE ISSUED G <br /> PERMIT EXPIRES 1 YEAR FROM DATER SSUED <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 Regulatio f„the San Joa uin Loca�l eaJ�th District. <br /> Job Address XlSubdiviSion Name 9 <br /> i. <br /> Owner's Name Address C C9 Phone <br /> Contractor's Na CdLicense No. Z�2 Z'� Phonea G V�:7rr <br /> r <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ,PUMP INSTALLATION [] SYSTEM REPAIR !❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IN' DISPOSAL FLO.#,`� PROP. LINE ' ) <br /> FOUNDATION AGRICULTURE`WELL :` �` 5OTHER;WEft- FITS/SUMPS Q _ <br /> INTENDED USE - w ___TYPEYOF WELL _ PROBLEM AREA .., _CONSTRUCTION SPECIFICATIONS 931 <br /> Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation <br /> U <br /> 'Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing <br /> Public � <br /> I—] ❑.Other ❑ Delta Type of Casing <br /> Lj Irrigation ” + Approx. ❑ Eastern Specifications 6 <br /> Cathodic Protection Depth <br /> ; Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> LJ Other f ° Surface Seal;Installed by <br /> Repair Work Done ❑ 1MType,of Pump H.P. State Work Done <br /> Well:Destruction ❑ Well Diameter + Sealing Material (top 50') <br /> 3 <br /> Depth 5 IFiller Material (Below 50') y 3.. ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,❑! REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is ' <br /> E / available within 200 feet.) <br /> Installation will serve: Residence �r .Commercial _ Other I <br /> Number of living unit's:_ Number..o'f._ drooms lot size 2 Y <br /> Character of soil to a depth of 3 feet: kw�,_ """"'"'"'"" wafter table - <br /> a <br /> SEPTIC TANK Lj Type/Mfg - :� �• _ Capacity ' No.rCompartments <br /> r` PKC. TREATMENT PLT. T e/Mf y� 1 p <br /> ❑ Type/Mfg g �` � Cap'aczt { Method of Disposal <br /> i SEWAGE SYSTEM Distance to nearest: Well Foundation ­4� .P_roperty Line <br /> DESTRUCTION ❑ s ~•. ,r�1 <br /> r LEACHING LINE No. & Length of lines f C +Total length/size C� <br /> ' <br /> FILTER BED ❑ Distance to nearest: Well _- Foundation / y Property Line_ _ F <br /> SEEPAGE PITSDepth Size 3 Number <br /> 5UMP5 ❑! Distance to nearest: Well �//U Foundation �Q Rroperty Line <br /> DISPOSAL PONDS �! <br /> I hereby certify that I have prepared this application and that the work will be dome in accordance with San Joaquin county r' <br /> ordinances,"state laws, and rules and regulations of the San Joaquin Local Health District. ' <br /> Home owner or 1"icensed agent's signature certifies the following: "I certify that in the performance of the work for which this f <br /> permit is issued,�I,,�halI 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.R' <br /> The ap,plicamust call r ti 1 required inspections. Complete drawing g►� . <br /> reverse-side. 5 <br /> Signed X Titl <br /> ` Date:/� 4 i <br /> f- - I <br /> FOR DEPARTMENT USE ONLY <br /> App ation Accepted by <br /> Are ❑ 5t k{ 466-6781 <br /> Additional Comments: Lodi' 369-3621 <br /> Pit or Grout Inspection b Date ❑ <br /> Manteca 823-7104 l <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copie to: Enviro mental Health Permit/Services 16D E, z°e]ton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO �� r .._ ---- ---- <br /> 4-f' 1j- <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br /> f <br />