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SUMPS Distance to nearest: Well vil-n/ f � DISPOSAL PONDS Li �"' I hereby certify that l 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 DistPi<. Home owner or licensed agent's signature certifies the fallowing: "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 or sub -contracting signature certifies the following: "1 certify that the performance of the work for which in this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant m call for all r uired inspections. Complete drawing on reverse side. Date: Signed X Title: FOR DEPARTMENT USE ONLY Stk 466-67$1 Application Accepted by Area - ,� Lodi 369-3621 Additional Comments: Manteca 823-7104 Pit or Grout Inspection b Date Final Inspection by Date b }c7 Tracy 835-6385 Applicant - Return all copies o. Environmental Heal i Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952 D1 FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ! > -SZ77-k `r' b 10/82 500 EH 13-24 REV. 10/82 14-26 APPLICATION FOR PERMiT SAN JOAQUi'; LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT "NO. Telephone (204) 466-6791 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) is hereby trade to the San Joaquin Local Health District for a permit to construct and/or install the work herein for or No. 1862 for well/pump �Jj Application described. This application is made in compliance with San Joaquin County Ordinance No. 549 sewage and the Rules and Regulations of the San Joaquin Local Health District. TS 9_ Job Address i, Su(ti vision Name 20 Phone Q 3 Owner's Name Address V 3� s Z Phone Contractor's Name License No. TYPE'OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR U OTHER LJ PROP. LINE FLD. DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSALPITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia. of Well Excavation LJ Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing i Public CjOther [] Delta Type of Casing V Irrigation Approx. Eastern Specifications Q Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout 1 U Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done r Well Destruction U Well Diameter Sealing Material (top 50') �-- N _. �. Filler Material (Below 50') f Depth vi TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage piavai ableewithinu200cfeet.sewe) is LI 7. , Installation will serve: Residence / Commercial _ Other Lot size Number of living units: _QS1. Number of be rooms -� Water table depth ' Character of soil to depth of 3 feet: No. Compartments SEPTIC TANK] Capacity Type/Mfg y Method of Disposal 3 ' PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Property Line b j, SEWAGE SYSTEM � Distance to nearest: Well Foundation . i1 DESTRUCTION Total length/size � LEACHING LINE No. & Length of lines 9 Property Line y FILTER BED Distance to nearest: Well Foundation f SEEPAGE PITS Depth 2 _i Size `s - Number s — i oundation Property Line , SUMPS Distance to nearest: Well vil-n/ f � DISPOSAL PONDS Li �"' I hereby certify that l 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 DistPi<. Home owner or licensed agent's signature certifies the fallowing: "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 or sub -contracting signature certifies the following: "1 certify that the performance of the work for which in this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant m call for all r uired inspections. Complete drawing on reverse side. Date: Signed X Title: FOR DEPARTMENT USE ONLY Stk 466-67$1 Application Accepted by Area - ,� Lodi 369-3621 Additional Comments: Manteca 823-7104 Pit or Grout Inspection b Date Final Inspection by Date b }c7 Tracy 835-6385 Applicant - Return all copies o. Environmental Heal i Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952 D1 FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ! > -SZ77-k `r' b 10/82 500 EH 13-24 REV. 10/82 14-26