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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6181 PERMIT NO. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED^�3 (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 Ordi and the Rules and Regulations of the San Joaq in Local Health District. nance No. 549 for sewage or Na. 1862 for well/pump Job Address division Name LM (pS Owner's Name sI Contractor's Name er ,!' ess hone 4� •� Cf-f� License No Phone /- 6� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION �� SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION P G' AGRICULTURE WELL OTHER WELL PITS/.SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , Industrial pen Bottom Manteca/ r ) ❑ Dia, of Well Excavation Ted-MmesticlPrivate Gravel PackTrac ❑ Public � y Dia. of Well Casing �j Other ❑ Delta LjIrrigation Type of Casing Approx. F-1Eastern Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal ❑ Other Type of Grout - Surface Seal Installed by `" 'Repair Work Done ❑ Type of Pump H.P, State Work Done ! Well Destruction U Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 501) _ TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if " public sewer is Installation will serve: Residence —Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth 01 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM, DESTRUCTION (� Distance to 'nearest: Well - Foundation Property Line LEACHING LINE ❑ No. & Length�iof lines Total length/size FILTER BED � ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS +. "� x= - I [j_ Depth Size Number SUMPS L=� Dstance,_to'nearesti�We11 Foundation h' `� 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�tle following: "1 certify that in the performance of `the work for which this permit is issued, I shall not employ any person in sich manner -as to become subject to workmah�<ompensation laws of California." Contractor's hiring or sub -contracting signature certifies the following;- "T certify -that in the performance of the work for which . this permit is issued, I shall employ persons subject to workman's compensation laws of California." The appl' nt must call for al uired inspections. Complete dra ing �on re`v�erse.-side. Signed X _._.: Tial -e: .� '�Y/v Date: DEPARTMENT USE ONLY Application Accepted by a ;:-,Area ❑ Stk 466-6781 Additional Comments: Pit or Grout Inspection by Final Inspection by Applicant - Return all copies Envi FEE BASE AMOUNT DUE INFO ezw 4L Date th Permit/Services AMOUNT REMITTED Tk e, EH 13-24 REV. 10/82 L �c ,• 14-26 RECEIVED BY Lodi 369-3621 Manteca 823-7104 Tracy 835-6385 zelton Ave., P.O. Box 2009, Stk., CA 95201 DATE PERMIT NO. 1D/82 500