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P � APPLICATION FOR PERMIT � 2 �1o�+R SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 EI U�]�"�e.(!e I� JQ d[ E. HAZELTON AVE., STOCKTON, CA PERMIT NO. IQ I ! /n Telephone (209) 466-6781 DATE ISSUED 1213`3 PERMIT EXPIRES I YEAR FROM 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 Regulations of theSan,Joaquin Loc 1 Health District. Job Address Subdivision Name �1i3 /m a Owner's Name Address Phone Contractor's NameA114111Z4 License No. Phone L/J TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION u3 PUMP INSTALLATION SYSTEM REPAIR OTHER .'? ) ` DISTANCE TO NEAREST: SEPTIC TANK /'� SEWER LINES DISPOSAL FLD. -� PROP. LINE W FOUNDATION AGRICULTURE WELL OTHER WELL / PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom E] Manteca Dia. of Well Excavation Domestic/Private lieGravel Pack Tracy Dia. of Well Casing �c Public [_1 Other Delta Type of Casing Li irrigation Approx. E] Eastern Specifications Cathodic Protection Depth Depth of Grout Seal s� Geophysical Type of Grout _ l U Other li Surface Seal Installed by e-.- V Repair Work.bone'o, Type of Pump —.4a Irl, H.P, i State Work Done 011 Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation:wil] serve: . Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK " Type/Mfg Capacity No. Compartments PKG,.TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE'SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line y. SEEPAGE PITS Cj Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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 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 workmans compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ person subject to workman's compensation laws of California." The applicant must c a n pec ons, Complete!7DZL!. Signed X itle: Date: !�^ ' FOR DEP RTMENT U ONLY e) Application Acc d by Area .Z Stk 466-6 Additiona omments: D Lodi 369-3621 Pit o Gro nspection by Date 0 Manteca 823-7104 Final Inspection by Date //-/J Y; ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. INFO EH 13-24 REV. 10/82P14-1 10/82 500 14-26