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3 ' 3 o <br /> APPLICATION FOR PERI"IT <br /> SAN JOAQUi'! LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3�• 1 p.� i <br /> Telephone (209) 466-6781 <br /> DATE ISSUED 1 <br /> PERMIT EXPIRES 1 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 instals 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 Regulations of the San Joaquin Local Health District. r /t +� <br /> Job Address j ' 1�1L U A4,At.1 _ � Subdivision1�(�Lj(J CAU —A" ` <br /> Owner's Name t11� �ZNaNaaCr1(4P-A7 •�T Address �CPVonus"] -7D <br /> Contractor's Name-77-$j&A-tom_ License No. -S'l� C Phone <br /> W1�• �1�1�1 II 1 R f <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR C1 OTHER J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PRD?. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [—] Industrial U Open Bottom F7 Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public Other Del to <br /> Type of Casing <br /> Lj Irrigation Approx. Eastern <br /> Cathodic Protection Depth Specifications i <br /> Depth of Grout Seal <br /> .17 <br /> Geophysical <br /> Type of Grout <br /> U Other Surface Seal Installed by i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done I <br /> Well Destruction L} Wel.1-"Diameter--- "O—Sealing-Material (top 50') _ <br /> Depth Filler aterial (Below 50') <br /> 7 _ , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDI I N J {No septic.tank or-seepage pit.permitted. ifrpublic sewer is <br /> C �T '' -avail-able within 200 feet.} I <br /> Installation will ve: es a. Other <br /> Number of living units Numt3erlo bedrooms i Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK U Type/Mfg Capacity No. Compartments G <br /> PKG g-TREATffrNT-t4T. Type/Mfg f% Capacity Method of Disposal <br /> SEWAGE SYSTEM pi•st n e to nea sL Well ` ndation r — Property Line <br /> pESTRUCTIDN <br /> HING L] U No, & Length of lines i Total length/size <br /> F[LTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size V.G Number <br /> SUMPS ( LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PWNUS ' <br /> � <br /> 1.11.1 <br /> I hereby clrt-ify 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 Health District. <br /> Home owner'or licensed agent's signature certifies the following: "O certify that in the performance of the work for which this <br /> permit is ]ssu I shall not employ any person;eZrtifie <br /> such manner as to?,become subject to workman compensation laws of California." II <br /> Contractor's h ring or sub-contracting signat s the following: "I certify that in the performance of the work for which <br /> this permit i issued, I shall employ p sons t to workman's compensation laws of California." <br /> The applic m s 11 for a requir insp tion . Compl a drawin d reverse side. / <br /> Signed X le: Date: <br /> FO DEPARTMEN E ONLY <br /> Application Accepted by AreaNtStk 466-6781 <br /> k i <br /> Q�na <br /> i�t'onal Comments: Lodi 369-3621 <br /> P /orlGrout Inspection by Date Manteca 823-7104 <br /> Fl Inspection by Date q Z— 3 Tracy 835-6385 <br /> Applicant - Return all copies to: vironmental Health Permit/Services 1601 1 E. Hazelton Ave_ P.Q. Box 2009, Stk., CA 95201 <br /> LINFO <br /> BASE _ AMOUNT. DUE AMOUNT REMITTED RECEIV�D BY DATE PERMIT NO. <br /> moll <br /> EH 13-24 REV. 10/82 _ - - - 10/82 500 <br /> 14-26 <br />