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l0�, l APPLICATION O SANJOAQUINLOCALHERLTHIpISTRICT 1601 E. pAVE., STOCKTON,.CA �� Telelephonehone (209} 466-6781 �`" PERMIT N0. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or 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 egu :ioof.the San Joaquin Loc Health District. Jab Address � jg PeA/r�'E Subdi ision ame Owner's Name ®it/ E�✓�� %Ah! Contractor's Name j � License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL [3 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION• ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK+ -_k l- SEWER LINES �`-- DISPOSAL FLD. PROP, LINE N FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS C> i INTENDED USE TYPE OF WELL PROBLEM AREA — y 1 CONSTRUCTION SPECIFICATIONS Ua Industrial ❑ Open BottomManteca ) ❑ Dia. of Well Excavation Domestic/-Private El Gravel ❑ Public ❑Pack Tracy Dia.-of Well Casing ❑ Other ❑ Delta Irrigation Approx, E] Eastern Type of Casing ❑Cathodic Protection Depth Specifications XL ❑Geophysical Depth of Grout Seal Other Type of Grout Repair Work Done Surface Seal Installed by F ° E] Type of�Pump " H p _ ` State Work Done o 1 1 Well Destruction X Well Diameter Sealing Material (top 501) T Depth Filler Material (Below 50') Tile YPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is vv ' .Installation will serve: Residence _ Commercial _ Other i available within 200 feet.) # Number of living units: Number of bedrooms Lot size r Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacit SEWAGE SYSTEM y Method of Disposal >� DESTRUCTION C1 Foundation to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total Tength/size FILTER BED E] Distance to nearest:- Well Foundation Property Line SEEPAGE PITS ❑ Depth ' 2 4k Size i , 1 t Number SUMPS fJ Distance to nearest: Well Foundation �`"' DISPOSAL PONDS Property Line 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 and regulations of the San Joaquin Lqcal 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 hi ng or sub-cant cting si nature certifies the following: "I certify that in the performance of the work for which this permit is is$ ed, I sh 11 ploy p s ns subject to•workman s compensation laws of California." The a 'can call f r i rer sped' rns. Complete drawing on reverse side. Sig X Title: ) Date:' FOR TMENT USEONL ' Application Accepted by rY Area Additional Comments: Stk 466-6781 ❑ Pit or Grout InspectiLodi 369-3621 on Date ❑ Manteca 823-7104 Final Inspection by .s4r,��ntan.wn� Date L- trr ❑ y 9 �� Trac 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.D. Box 2009, Stk., CA 95201 i FEE BASE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT N0. i EH 13-24 REV. 10/82 14-26 500 � 10/82 `