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APPLICATION FOR PERMIT <br />t SAN JOAQUIN LOCAL HEALTH DISTRICT <br />3 <br />• 1601 E. HAZELTON AVE., STOCKTON, CA IT N0. <br />Telephone (209) 466-6781 4 A JQA7 <br />r DATE ISSUED <br />,L__i , <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />MA <br />` (Complete in Triplicate) ENVIROMENTAL H�.EkLTH <br />i Application is hereby made to the San Joaquin Local Health`District for a permit' to ? TJK(�age or 'the work herein <br />:described. This application is made in compliance with San Joaquin County Ordinanc �f�o+r�'s�ewage or No. 1862 for well/pump <br />and the.Rules and Regulations of the San Joaquin Local Health District. _ <br />Job Address{ /Q/!�~ E �•7 on Nam,5 uG/oe <br />rG J — Y <br />Owner's Name 1iF).!1 a{ /Er/ / Address i� /�- ��_17I Phone <br />Contractor s Name l A/ UI.Qi''X� 1iPIl/ <br />License No. Phone <br />TYPE OF WELL/PUMP WORK: NEW WELL ! WELL REPLACEMENT. F = DESTRUCTION U <br />PUMP INSTALLATION �� SYSTEM REPFIR;,,,_._]..� _- <br />f -'�" " — �- DISPOSAL FLO. PROP. LINE <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br />i FOUNDATION AGRICULTURE WELL OTHER WELL <br />INTENDED USE TYPE OF WELL <br />'Industrial (=J Open Bottom <br />Domestic/Privates 'Jj5�,Gravel4Pack <br />PROBLEM AREA LUNSIK <br />F-IManteca Dia. <br />{ ..TracyDi-a: <br />?� Public U Other ` Delta Type of Casing <br />Irrigation Approx. [] Eastern Specifications <br />Depth Cathodic Protection Depth of Grout <br />t <br />[]Geophysical Type of Gr ut <br />t U Other Surface S 1 1 <br />J State Work <br />Repair Work Done � Type of Pump H•p•+------ <br />Well Destruction Well Diameter I Sealing Material (top.50') - r <br />Depth t Filler Material (Below 50') �? <br />WORK: 'NEW INSTALLATION -El REPAIR/ADD TION U '(No septic 'pit permitted if public sewer is <br />TYPE OF SEPTIC W0 l— z t eptic ta.. available within 200 feet'). <br />Installation will.serve: Residence _ Commercial -.,,.,Other.. <br />.. <br />' '` `f+y Number of bedrooms V '.Lot size <br />f5wNumber of living units: ; Water table depth <br />Character of soil to a depth of 3 feet: No. Compartments <br />SEPTIC TANK [—I Type/Mfg I Capacity <br />{ Capacity. Method of Disposal <br />R# PKG. TREATMENT PLT. ❑ Type/Mfg - Property Line ' <br />-.SEWAGE SYSTEM Distance to nearest: well foundation P Y <br />}' DESTRUCTION t <br />LINE u No. & Length of lines i Total length/size <br />LEACHING LINE Property Line <br />FILTER REO Distance to nearest: Well <br />Foundation <br />I SEEPAGE PITS Depth Sim <br />'^ Number <br />I <br />� SUMPS LI Distance to nearest: Well Foundation Property Line <br />- _DJSPOSAL PONOS ..� •••. ': +* " ' _ <br />I hereby certify that I 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 Joaquin Local certifflealth that insthecperformance of the work for which this <br />Home owner or licensed agent's signature certifies the ollowing- y <br />(permit iiissued, <br />I shall ncantract�ngnsignaturejcertifiesn such nthe followner as to ing meIscertifyubject tthatrinathecperformance ofwthe work �for nwhich <br />or persons subject to workman's compensation laws of California." <br />this permit is,issued, I hall employ. p - <br />The applicant st 11 or al a aired inspections. -Complete dra g.on verse Date:-� <br />Signed X Title <br />DEPARTMENT USE ONLY (� Stk 466-6781 <br />Application Accepted by Area <br />i <br />Additional Comments: <br />i Pit:or Grout Inspection by <br />Final. lnspection'by- <br />Appl i <br />EJ Lodi • ' 369-3621 <br />)< Manteca 823-7104 <br />Date Tracy 835-6385 <br />- - •-,�an�,*t, pe`rmif/:Services 1601 E. Hazelton Ave_, P:OrBox2009, Stk.,••OA 95201 <br />Eli 13-24 REV. 10/82 <br />14-26 <br />10/82 500 <br />