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r/ (ir g APPLICATION FOR PERMIT �w k y.• SAN JOAQUIN LOCAL HFALTH DIST,RICT 1601 E. HA2ELTON AVE., STOCKTOhI, CA IT N0. Telephone X209) 466-6781 ,r t ,.� E ISSUED �ZS—�3 I PERMIT EXPIRES 1 YEAR FROM .DATE ISSUCi�g.� ° _rp� (Complete in Triplicate) Application is hereby-made to the'San 'Joaquin Local Health District for a permit to construct a�,+ install the work 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 of the San Joaquin Local Health District, g,+ Job Address y�.�. t.� zl/ Y. & Subdivision Name Owner's Namer. „Phone �a JCl { - � Address c.. (' 1T_ _�¢ T/ Contractor's Name License No. d T Phone r TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION _J PUMP INSTALLATION SYSTEM REPAIR LI OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE ,FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I JIndustrial ' U Open ottom � Manteca Dia. of"Well Excavation Domestic/Private F-1 Gravel Pack ❑ Tracy Dia, of Well Casing ! Public F-1Other ❑ Delta Type of Casing �j Irrigation Approx. Eastern ❑ Depth Specifications _Cathodic Protection p Depth of Grout Seal {L] Geophysical U Other Type of Grout ' Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction F-1 Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION C) (No septic tank or seepage pit permitted if public sewer is 4 Installation will serve: Residence � Commercial _ Other 4 available within 200 feet.) Number of living units: Number of bedrooms Lot size n Character of soil to a depth of 3 feet: Water-table depth 'SEPTIC TANK U Type/Mfg Capacity NO. Compartments PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal ' SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION �l LFACHING LINE U No. & Length of lines Total length/size 3 FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ej Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1 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 and regulations 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 workmanIs compensation laws of California." C6ntractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which (� this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." r�1 The applicant must call for all required inspections. Complete drawing on reverse side. Signed X — � Title: hate: FOR DEPARTMENT USE ONLY Application Accepted by Area — Q . 1 _ [N_Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date L] Manteca 823-7164 Final Inspection by Date ��--i" ❑ Tracy. 835-6385 Applicant - Return all copies to: Environmental Health Pe it/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE. AMOUNT REMITTED RECEIVED BY DATE PERMIT,NO. INFO MLAS _,C� n X53 75 EH 13-24 REV. 10/82 10/82 500 !14-26