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�. APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DiSTRICT <br /> - ° <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. .� <br /> Telephone (209) 466-6781 DATE ISSUED <br /> PERMIT ERPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> • I <br /> rein <br /> Application is herebymaoiincompliance Joaquin <br /> detothe <br /> SanolwHealth District <br /> for <br /> a permit <br /> inan�ecNnStt <br /> 549ford <br /> sewage sorlNo. 1862tal the rfor ewell/PUMP <br /> described'. This apP <br /> and the Rules and.Regulations of„t . San Joaquin Local Health District. <br /> !/!/ Subdivision C Name <br /> Job Address Phone <br /> Address �l <br /> Owner's Name /! Phone <br /> Contractor's <br /> License No. <br /> ” Name ' <br /> ' NEW WELL DESTRUCTION <br /> TYPE OF WELL WORK: WELL REPLACEMENT � ❑ � <br /> f ; <br /> PUMP INSTALLATION" SYSTEM REPAIR OTHER USEWER LINES DISPOSAL FLO. /iD PROP• LINE._ <br /> 41 ! <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL _ <br /> INTENDED USE ;I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ff I <br /> IJ Industrial <br /> U Open Bottom [Manteca Dia. of Well Excavation Z2/ <br /> Trac Dia. of Well Casing <br /> Domestic/Private O Gravel Pack ❑ Y <br /> Public Other [J Delta Type of Casing <br /> Irrigation I Approx. EJ Eastern -Specifications <br /> (J <br /> ❑ Depth Cathodic Protection Depth of Grout Seal <br /> 4 �Geophysical <br /> Type of Grout <br /> I !� Surface Seal Installed by <br /> U Other J <br /> T e."of Pum H.P, v� `State Work Done <br /> Repair Work Done �f YP p V 1 <br /> Well Destruction U Well Diameter �__.� <br /> Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br />• _ ' it permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW,:INSTALLATION 7I REPAIR/ADDITION U (No #eptic tank or seepage pit <br /> within 200 feet.) <br /> --4 <br /> Installatidn wi"11 serveil: Residence Commercial Other Lot size ��l <br /> Number of living units- Number of bedrooms th <br /> —•�— <br /> f - Water table dep <br /> Character of soil to a depth of 3 feet: Capacity � No. Compartments <br /> SEPTIC TANK ❑ 1IType/Mfg Capacity Method of Disposal _ <br /> PKG. TREATMENT PLT. Type/Mfgtion property Line <br /> SEWAGE SYSTEM C] Distance to nearest: Well Founda) 0 <br /> DESTRUCTION <br /> Total length/size <br /> LEACHING LINE U No. & Length of lines Property tine <br /> FILTER BED iI Distance to nearest: Well Foundation <br /> Size Number <br /> SEEPAGE PITS �1 I� Depth �____ <br /> IFoundation Property Line <br /> SUMPS EV `i Distance to nearest: Well <br /> i DISPOSAL PONDS <br /> I hereby ceror which this <br /> statetify that I'[anderulesaand regulaPponsaof thetion n Sanhat Joaquenwork Localill Healthdone Distrnctccordance with San Joaquin county " <br /> ordinances, <br /> ork <br /> Home owner or licensed agent's signature cerson1ein suchfmannnernas to becomeysubjectthat ntohworrkmans compensate performance of honwlaws fof California." <br /> permit is issued, Ishall not employ y Pfollowing:.,, y p <br /> Contractor's hiringor sub-contractingsignature <br /> ubjectltoeworkman'sccompensationrlaws ofCalifornia." <br /> of the work for whit <br /> this permit is issued, I shall employ p Complete draw or—reverse side. <br /> i i <br /> k The applicant must c _ tate: <br /> Title: <br /> Signed X j <br /> FOR D PARTMENT USE ONLY Area / E] Stk 466-6781 <br /> _�__ <br /> Application Ac ' ted by ,` Lodi 369-3621 <br /> Additional Comments: Date j 7 Manteca 823-7104 <br /> r Pit or Grout Inspection by pate /[�/ Tracy 835-6385 <br /> Final inspection by Ave P <br /> Applicant - Return alllcopies to: Envir nmental Health Permit/Services 6 1 E. Hazelton .O. Box 2008, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED _S_4_�4 t <br /> RECEIVED '8Y DATE PERMIT NO. <br /> INFO ��il{� _1O � . <br /> � IO/82 500 , <br /> EH 13-24 REV. 10/82' r <br /> 14-26 <br />