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.� APPLICATION FOR PERMIT <br /> t <br /> A{ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �j 1601 E. NAZELTON AVE., STOCKTON, CA PERMIT 10, Cj its j <br /> A Telephone (209) 466-6781 DATE ISSUED,�=� <br /> PERMIT EXPIRES I 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 compliance with San Joaquin County Ordinance No, 549 for sewage or filo. 1862 for well/pump , <br /> and the Rules and Regulations of the SAn qutn Lpcal Health District, <br /> Job Address yam- Subdivision Name r <br /> ` Phone <br /> Owner's Nairne !r"` BAR. t fir + Address 1 ._._ �f ��-f - <br /> Contractor's Name � '�, , =,ram license No. Phone <br /> , <br /> TYPE Of WELLIPUMF WORK: NEW WELL #� WELL REPLACEMEN? [ DE57RUC?iOli{J <br /> PUMP INSTALLATION SYSTEM REPAIR <br /> �Y ..�U� OTHER FJ �+ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIKES 11 DISPOSAL FLO. _ PROP. LIKE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUIIPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIDN SP£CIFICATIO?B " <br /> f <br /> [_1 Industrial _ F-1 Open Bottom Manteca Ilia. of Well Excavation �) <br /> � Ll Domestic/Private Gravel Pack r Tracy Ola. of Well Casing <br /> C]Public j Other C 3 Delta Type of Casing <br /> L Irrigation - Approx.�,,. ``1 EaStern. . .-»� -w.-=-�p��Lotions <br /> i Cathodic Protection �/ M �sOepth .�:::- <br /> [vJ Depth of Grout Seal <br /> ' GeophysicaI Type of Grout _ ,...._ <br /> Other <br /> Surface Seal Installed by l� <br /> Repair worn: Done G Type of Pump � H.P. _.._ State Work Done � J <br /> r; <br /> Well Destruction Well Diarrvxter _. Sealing Material (top 50') <br /> Depth Filler Material (Below 50', <br /> ` TYPE OF SEPTIC WORK: NEW INSTALLATION „J REPt+IR/ADO;TIDN {Nn septic tank or Seepage pit permitted if public sewer is <br /> available within 20c1 feeL.> <br /> j Installation will serve: Residence V Commercial _ Other <br /> Number of living units: er of bedrooms Lot size _. ' <br /> Character of soil to a depth of 3 feet: ��'$J� _ -Water table depth _ <br /> i <br /> 3 S£PIIC TANX F4 Type/Mfg 'P � C _ti Capacity - resp No. Compartments �," <br /> i <br /> PKG. TREATMENT PLT. C ;ype/Mfg s Capacity Method of Disposal - <br /> Distance to nearest: .leli Foundation -4­ 6-00—f�prop eriy;Line <br /> Septic Tank � ?_ - -- <br /> j�estr�tic�T.�l <br /> r Fr ,Total length/size I riar �_w <br /> i <br /> LEACHING LINE [� No, b Length of lines _ _ �-- <br /> FILTER BED �[� Distance to nearest: Well y Foundation PropertylLine <br /> SEEPAGE PITS Depot Size Number --- <br /> SUMPS Distance to nearest: Well FounndationPraperty-Line _ <br /> DISPOSAL PONDS CI �"" :' . r. •. i �� s3 ��s.._ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules And regulations of:the.San_Joagvin Local Health District, <br /> Home owner or licensed agent's sigr8ture certifies the following: "1 certify that`in the performance�of't{iif viorii for which this <br /> permit-is issued, Ishall neml� <br /> (lot ploy any person"in s4ch•manner -tb-secome subject to woryman�compensation laws of California." <br /> Contractor's hiring or sub-Contracting signature certifies the-fbllowirig: "I certify that in the performance of the work for which <br /> F this permit is issued, i shall employ-persons subject to workrmn's compensataon'laws of California.." <br /> The applicant must call ~or- _+require inspect ions. Cnmplete'deawin§ on reverse side. <br /> Title: e�'��� �- Nate: <br /> i. Signed X _ <br /> �EP ENT USE ONLY Area Stk 466-6781 <br /> Application Accepted by _- <br /> Additional Coartents: _ Lodi '369-3621 <br /> Pit or Grout Inspection by _ Date Manteca a23-7104 <br /> Final Inspection by _Date Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental 3 Permit/Services 1 01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520I <br /> FEE BASE AMOUNT DUE AVUNT REMITTED RECEIVED By, _ DATE -PERMIT NO. <br /> �. INFO _ <br /> Eh 13-24 REV. 10/82 10I82 540 <br /> IA-26 <br /> l <br />