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APPLICATION FOR,.PERMIT . SAN JOAQUIN LOCAL"HEALTH DISTRICT _ 1601 E. HAZELTON.AVE., STOCKTON, CA "PERMIT h0:` Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r r (Complete in Triplicate) to f Application is herebyionis mad iothe San icw JoaquiniLLocal Health ith District for ountypermit ancecNo. 549td forsewage sorlh Not1862rfor ewell/pump described. T pP at and the Rules and Regulations-of-the San J_4aquin Local Health District. i _ r/ LTA' Subdivision Name Job Add-P2ss _1 = ' ' G(1 r�—r� — Phone � Owner's Name '��Address _:; as' Phone Contractor's Name � d � �u.Il�-r" License No. TYPE OF WELL/PUMP WORK: NEW WELL �] WELL REPLACEMENT ❑ DESTRUCTION c� PUMP INSTALLATION []- SYSTEM REPAIR ❑ OTHER ❑ V 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T-—T . ,,,,,,r., -- .-- ---� : Dia. of Well Excavation _ ❑ Industrial �Open Bottom; ❑Manteca T � _ t lJ Domestic/Private Gravel Pack ;Q'Tmacy Dia. of Well Casing Public , Other a ❑ Delta Type of Casing L7 E: lrragation 1 Approx.`�"`�❑ Eastern`` # specifications ❑Cathodic Protection Depth�-� Depth of Grout Seal ❑Geophysical Type of Grout t ❑Other Surface Seal Installed by ' Repair Work Done Q Type of,Pump H.P. state Work Done Well Destruction EJ Well Diameter 1 Sealing Material (top 50') j ller`Material ;(Below 50') ' Depth TYPE Of SEPTIC WORK: NEW,,INSTALLATION PA]R/ADDITION ❑i (No septic tank or seepage pit availableed if withinu200cfeet) is Installation willSserve Residence Commercial Other {{ Number of bedrooms Lot size,,;c Number of living units; l�_ a Water table depth Character of soil to epth of 3 feet: 11 No, Compartments Capacity I SEPTIC TANK Type/Mfg Method of Disposal p PKG. TREATMENT PLT. ❑ } rY4pe/Mf`g_ �J ."Capacity i Property Line SEWAGE'SYSTEM "Di"stance to nearest: Well Foundation P F DESTRUCTION ❑ € '� _ qt LEACHING LINE Foundatio�9'�` Property LineNo. & Length of lines T 1 length/size x •�[1 � � � - v +'3 I FILTER'BED 1,_6i❑ stance to nearest: .,Wel,ly`,` � (� Depth th Size Number SEEPAGE PITS ❑ p � -- Property Line ` SUMPS ❑ Distance to nearest: Well Foundation ; DISPOSAL PONDS ❑ �" .r 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 l certifHealth that insthect. performance of the work for which this Home owner or licensed agent's signature certifies the following: Y permit'is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of Californiac Contractor's hiring or sub-,contracting signature certifies the for"I 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 applicant must call fo all,required inspections. Complete drawi�g on rever a side. Date: ' Signed.X + Title: Q - I i OR DEPART NT USE LY �q/ E] Stk 466-6781 ' Applica#ion Accepted by � Area _.�L- �' Lodi 359-3621 �Additionad Conn nts:,,, �` ❑ Manteca 823-7104 f i �nspecti - Date 6 or Gro1"ut Ion by Tracy 835-6385 ,0 Final Inspection by, Date L Applicant - Return all copies to: Environment 1 Health Permit/Services 1601 E. Hazelton Ave., P.O., Box 2009, Stk., i5201 ' DATE PERMIT N0. k FEE BASE AMOUNT" DUE AMOUNT REMITTED RECEIVED BY INFO b - 10/82 500 EH 13-24 REV. 10/82 - 14-26