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{ APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL' HEALTH DISTRICT �q 2 J f <br /> 1 1501 E. HAZ£LTON AVE., STOCKTON, CA PERMIT N0. Q✓ <br /> Telephone (209) 466-6781 0- 1- <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete it Triplicate) <br /> Replication is hereby"made to the San Joaquin Local Health District for a'permit to construct and/or install the work herein <br /> r <br /> described. This application is made in compliance with San Joaquin count ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and R[g�gul ions of the San Joaquin Local ealth District. <br /> Jab Address / J i Subdivision Name . <br /> f Address j60( Phone <br /> Owner's Name --- <br /> Contractor's Name f ��_,9ackiud _ License No. �e Phone W <br /> E � <br /> TYPE OF WELL/PUMP WORK: NEb1 WELL ❑ WEL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM �1 k ��. OTHER U <br /> ' '+-D;ISPOSAL"FLD .. PROP. <br /> DISTANCE TO NEAREST: SEPTIC TANK.; 'SEWERLINES - - <br /> FOUNDATION AGRICULTU E WELL OTHER WELL t,_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA,. CONSTRUCTION SPFCIFICATIONS`N <br /> ` Dia. of Well Excavation <br /> "M 1 <br /> !J Industrial U Open Bottom anteca~ <br /> Trac Dia of Well Casing <br /> U <br /> Domestic/Private � Gravel Pack � Y <br /> u � <br /> Public Ot 4r ❑Delta ype of Casing <br /> E] Irrigation { Approx. E] Eastern Specifications - <br /> Cathodic Protection Depth <br /> D h of Grout Seal err ! <br /> Geophysical � <br /> Type of Grout <br /> U Other '' Surface Seal Installed by '�-z # <br /> ' H.P. <br /> State Work Done <br /> - Repair Work Done FJ Type of Pum <br /> x, Sealing Material (top 50') <br /> 0 Well Destruction U Well Diameter 9 - <br /> ' Filler Material (Below 50') <br /> Depth <br /> TYPE <br /> 1 OF SEPTIC WORK: NEW INSTALUTION X1 REPAIR/ADDIT' ONu U (No septic tank or:seepage pit permitted if public sewer i <br /> S .tM available within 200afeet.) <br /> ' 41 <br /> installation will serve: Residence Commercial Other-/` <br /> �- g (�` - Lot size �� i...l <br /> _ Number of living units: Number of bedrooms <br /> "'"' iWater table depth <br /> j Character of soil to a depth of 3 feet: ��_� t- k s e r <br /> ' ! Ca achy 1 �6 No. Compartments <br /> 'SEPTIC TANK Type/Mfg �f p 3 s{ <br /> r Capacity " Method ofDisposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg �_- - <br /> SEWAGE SYSTEM Distace to nearest: Well f r t Foundatiln Pro Line# a <br /> I DESTRUCTION - f <br /> No. & Length of lines `r` Total length%size <br /> TEACHING LINE 9 �� <br /> FILTER BED ll sFoundation f i Property Line I <br /> .., <br /> Distance to nearest: We =- —�r <br /> Size �< - �t 1 <br /> SEEPAGE PITS Depths Number <br /> ► Property Line <br /> SUMPS L! Distance to nearest: Well �10 <br /> n Y <br /> DISPOSAL PONDS ❑ <br /> I herebycertify that I have prepared this application and that the ork 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 performance of the work for which this <br /> Permit is issued, I Shall not employ any person in such manner as subject to workman compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies.tFie,following: "I certify that in the performance of the work for which <br /> i! this permit is issue I shall 'employ persons subjeyt'�to'wbrkman's compensation laws of}Cal' foinia-," J <br /> r <br /> ' <br /> The applicant must a for alli equire inspections. Complete drawing o�r-evers�e..+side# Dater <br /> s 'T1 tl e: /�rsa Y�i_dti I:('!`TY� <br /> s 'r Igngned' f , <br />[ DEPARTMENT USE ONLYr� � *� Stk '466`6781 <br /> I Application Accepted by Area. .� <br /> (� Lodi 369-3621 <br /> ` Additional Comments: .•hlanteca 823-7144 <br /> a Date <br /> Pit or Grout Inspection by <br /> Final Inspection by <br /> Date A tom, ❑ Tracy 835-6385 <br /> Applicant`- Return all copies to: . Environmen �lth Permit/Services Ib01 E. Hazelton Ave., P.O. Bax 20D9, St k., CA 95201 <br /> FEE <br /> INFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> r 14-26 <br />