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;y APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HA'ELTON AVE., STOCKTON, CA PERMIT N.O. P3- S 3 $ <br />Telepnone (2Cg) 466-5781 <br />PERMIT E%PI RES 1,YEAR FROM DATE ISSUED DATE iSSUEC Cr' C! J <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. 543 for sewage ar No. 1862 'or well/pump <br />and the Rules an. P.eculations ' the SanAJoaqui Local Health District. <br />Job Address_ Subdivision Name <br />Owner's Name Address Phone <br />Contractor's raj Lyre No,i �� T Phone <br />146)' <br />TYPE OF WELL/PUMP WORK: NEW WELL Ir <br />- - L BELL REPLACEMENT 1�. DESTRULTION (� <br />PUMP INSTALLATION C3 SYSTEM REPAIR OTHER <br />DISTANCE TO NEAREST: SEPTIC TAN:{ ^ SEWER LLN£S DISPOSAL FLD, PROP_ LINE <br />FOUNDATION AGRICULTURE WELI. OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL <br />PROBLE`! AREA <br />CONS -RUCTION SPECIFICATIONS <br />17 Industrial <br />? IOpen Bottom <br />Manteca <br />Dia, of Well Excavation <br />L( Domestic/Private <br />Graved Pack <br />Q Tracy <br />Dia. of Well Casing <br />a Public <br />j� Other <br />�] Delta <br />L Irrigation <br />_ Approx, <br />Eastern <br />Type of Casing <br />' <br />JCathodic Protection <br />Depth- <br />Specifications <br />Geophysical <br />Depth of Grout Seal �1 <br />17 Other <br />Type of Grout - <br />Repair Work Done <br />Well Destruction <br />Surface Seal Installed by <br />Type of Pump H.P, State Work Done <br />Well Diameter Sealing Material (top 501) <br />Depth Filler Materilh(Bellw 1p') i <br />TYPE OF SEPTIC WORK: NEW INSTALLATION jJ REPAIR/ADDITION [' (No septic tank or seepage pit permitted if public Sewer is <br />Installation will serve: Residence r�1,�} Coiavailable within 200 feet.) <br />anerciai Other <br />Number of living units: Numb of bedreoms Lot size +� t tf f <br />Character of soil to a depth of 3 feet: dater table depth 70 <br />SEPTIC TANK ❑ Type/Mfg . _ Capacity No. Compartments _1 1 <br />PKG. TREATMENT PLT'. Type/Mfg Capacity i Method of Disposal _ <br />SEWAGE SYSTEM Distance to nearest: :Weil Foundation, No Property Line - <br />DESTRUCTION -- — --- <br />LEACHING LINE j_j No, A Length of lines, Total Teneth/size <br />FILTER BED Distance to nearest:Well Foundation _ Property Line <br />SEEPAGE PITS ❑ Depth �Sizei Number <br />SUMPS _) Distance to nearest: FWeli _ Foundation Property Line <br />DISPOSAL PONDS =; " <br />T 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 Health District. <br />Home owner or licensed agent's signature certifies the following: "I certify that in the per=ormance of the work for which this <br />permit is issued, I shall not employ any person in such manner as to become subject to workmank 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." <br />The app]ica mu all foraequired inspe ns. Complete drawing on reverse side. <br />Signed % Title, L Date: <br />,,TMEN SF ONLY <br />Applica ion Accepted Area -�� Stk 466-678 <br />_. . -- <br />Adaitional Comments: Lod 3 - 621 <br />Pit or Grout Inspection by _ Date L_t Manteca 823-7104 <br />Final Inspection by ' _— Date �+ L Tracy 835-6.385 <br />Applicant - Return all copies to:. Environmental Health Permit/Services 1601 E. Hazelton .Ave., P.O. Box 8'009, Stk., CA 95241 <br />fEE I SASE AMOUNT DUE AMOUNT REMIi'TED .RECEIVED BY " -DATE P=RMiT N0. <br />IN j� -- <br />1 024 <br />EN 13-24 REV. 10/82 10182 600 <br />14-26 <br />