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" s APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1. 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 yyy DATE yISSUED rt PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , i (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework herein } described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations "hof th San Joaquin Local Health District. t Job Address 400 j G Subdivision Name -Owner's Name Address Phoney Contractor's Name a"'&_ License No. Phone TYPE OF WELL/PUMA WORK: NEW WELL �] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR C] OTHER DISTANCE TO NEAREST: SEPTIC TANK} SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 77-` AGRICULTURE WELL OTHER WELL 411 _ PITS/5UMPS ' INTENDED USE TYPE OF WELL .PROBLEM AREA '.CONSTRUCTION SPECIFICATIONS 1-1 Industrial— y r. Q`8pen Bottom []Manteca. ,; Dia: of Well Excavation - Domestic/Private -� D r 17 � Gra,yel: Pack � Tracy ia. of Well Casing . t;� � L7 Public 4, Othgr� Delta 'Type of Casing i F1 Irrigation ( `' Approx. L] Eastern Cathodic Protection Depth Specifications Geophysical 1 A : , *� Depth`of� Grout Seal # r Typeof Grout Other !� � g` Surface Seal Installed by Rep a'ir- Work Done ,Type of Pump, 1 ` H.P. i`�°`A,�_,State WorVDone Well Destruction' ;Well Diameter t Sealing Material (top 5()1,),-. Depth Filler Material (Below 5O. . :A TYPE OF SEPTIC WORK:. NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit*permitted if public sewer is t favailable within 200 feet.) . Installation will serve: Residence _ Commercial Other Number of living units: Number 1t i of..bedrooms "`" -�� °- _ � .Lot size.__ Character of soiQ 'to a depth ofr3 fee} =� ptr Fir`--�_�.�Q f .� Water table depth SEPTIC TANK ` i TypeiMfg�A,.,`��' .. 'Capaci'ty No 'Compartments PKG. TREATMENT PLT. Type/M -Capacity Method of Disposal Septic Tank �i stanc to"nearest: Wel l '.- _ �`Foundation• Property Line i Destruction 4 } ! LEACHING LINE U No. & L ng#h 0f' ines >Total length/size ' FILTER BED Distance to nearest: Well �1��Foundationt 4�,, � Property Line !4:,r-Q r �I SEEPAGE PITS Depth R ) Size Number SUMPS U Distance to nearest: Well Foundation] Property-Line DISPOSAL PONDS ' �j I hereby certify that. I have prepAred;this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules landaregulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this ., permit is issued, I shall not employ,any person in such manner as to become subject to workman§ compensation laws of California.'-` Contractor's hiring „o`r sub-contracting' signature certifies the following: '`;I certify that in-the performance of the work-for which this permit is issued;, I shall employipersons subject to workman's compensation laws of California." They ppl�icant must callor a req fired inspections. Complete drawing on reverse side. Sig d X ' 1 l Title: Date: t If FOR 0 ARTMENT USE ONLY Q t Application Accepted by Area Stk 466-6781 + rii "Additional{`Comments: ' i 0 Lodi 369-3621 {B N t or Grout tInspection by '' Date ❑ Manteca 823-7104 ! Final Inspection by j� Date 7-�,0- a E'Tracy 835-6385 1 Applicant ='Return-A 1 copies to: ;;Environmental Health Permit/Services 1601E Hazelton .Ave.; P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT .,-_..,AMOUNT REMITT.ED- RECEIVED-BY•- -- DATE PERMT'T NO " INFO' . J e �s EH 13-24 REV. 10/82 10/82 500 14-26 .3 3