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/5 Q 0`�G✓�'',euv/rte a APPLICATION FOR PERMIT �C/� p�� d� UZ SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. E Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED (1to pl.ete in Triplicate) ;I Application is hereby made to the' San JoaquG ii nLooca a District for a'permit to construct and/or install the work herein 11 described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. F Job Address i®. O lio Me Owner's Name Address Phone Contractor's Name /y[. License No. Phone WELL REPLACEMENT DESTRUCTION i 4r TYPE OF WELL/PUMP WORK: NEYJ WELL k p .y [] � ❑ i PUMP INSTALLATION SYSTEM REPAIRL _ OTHER DISTANCE TO NEAREST- SEPTIC TANK v6 � ' SEWER LINES 3 DISPDSAL FCD. PROP. LINE; ? FOUNDATION ' +AGRICULTURE WELL__.—.._ 1Y. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA% CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ OpenBottoms []Manteca+ Dia. of Wei1`E--- -Y i 1 kcdvation Domestic/Private `� Trac _ 17 � Gravel Pack�' ❑ , y µYa. Dia, of Wel l Casing k Public ❑Other -n, Q Delta IrrigationType:Approx. Eastern of Casing ❑ Cathodic Protection iDepth � Specifications r. ' Geophysical i, 'Depth of Grout Seal y, c } ❑_Other } � I 4a � Type of,Grout Surface{Seal Installed by- Repair "! t 4 1 Work Done ❑ Type of Pump { H•P, c-� �. r 'State Work Done r 4 N I Well Destruction ❑ Well Diameter! Sea ling Material�(top 52') Depth 1 -c !-Filler Material (Bel ow-,501 � TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION U p pg tpit permitted if public sewer is U (No septic tank or see a e 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 3rfeet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg i Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: 'Well Foundation Property Line e' DESTRUCTION F11 f f LEACHING LINE U No. J4 Length of lines Total length/size. y4 f FILTER BED Distance to nearest: Well Foundation Property Line f ,a SEEPAGE PITS ❑ Depth A Size � Number � SUMPS r L—� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D } I hereby certify that I have prepared this application and that the work will lbe•done in accordance with 5an--Joaq"uin -I'"• ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Dip , Home owner or licensed agent's signature certifies the following: "I certify that in' the performance of the work for which this ;,f permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California. Contractor's hiring or sub-contracting signature 'certifies the following: "'Icertify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensation,laws of California." x The applicant must call for all required inspections. Complete drawing on reverse side. r Signed X Date: FOR DEPARTMENT USE.ONLY + r Application Accepted by 5 Area = Stk 466-6781 Additional Comments: r .Lodi 369-3621 Pit or Grout Inspection by Date I Manteca 823-7104 il! Final Inspection by Date ❑ Tracy 835-6385 p Applicant - Return all copies.to: Environmental•Health. Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stkl CA\95201 FEE BASE AMOUNT DUE " BYAMOUNT REMITTED RECEIVEDDATE PERMIT NO INFO n E i w --FH.13-24 REV: 10/82 14-26 .. s