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APPLICATION FOR PERMIT'{ SAN JOAQUIN;LOCAL.HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON„CA PERMIT NO. Telephone (209) 466-6781 ' DATE ISSUED i PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete' in Triplicate) y r _ 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 Na. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address_ _�j`� �f✓ fa�P Subdivision Name'' " 4{ Owner's Name QI-n 6 Address ?` !�'Ruo- ,,, Phone Contractor's Name License No. .i Phone TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT E] DESTRUCTION PUMP INSTALLATION EJ SYSTEM REPAIR' OTHER - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial AL ❑Open Bottom J7�-Mante a Dia. of Well Excavation a Domestic/Private U E]Gravel Pack Tracy Dia, of Well Casing 17 Public ' other Delta Irrigation Type of Casing U 9 Approx. []Eastern - � l Specifications .� ❑Cathodic Protection Depth - ,1 Depth of Grout.Seal EJ Geophysical otherTYPe of Grout 1. U Surface Seal 'InstalTed by Repair Work Done ❑ Type of Pump H.P. State Work Done t- .� Well Destruction F-1 Well Diameter Sealing Material (top 501) �- �,` Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L PAIR/ADDITION +(No septic tank or seepage pit permitted-if,public sewer is available within 200 feet.) Installation will serve: Residence.._ Commercial Other w Number of living units: J- Number of-bedrooms Lot size y Character of soil to a depth of 3 feet: 6 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 _ _❑ A••1 LEACHING LINE No. & Length of lines f- ( 13 (� Total length/size,,j FILTER BED F-1 Distance to nearest: WeI1.�� oundation Property Line _ SEEPAGE PITS E) Depth Size NumberT SUMPS IJ Distance to nearest: Well Foundation Property,Line DISPOSAL PONDS I hereby certify that 1 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 Lqcal Health District I Home owner or licensed agent's signature certifies the following: "i certify that in the performance of the work for which this .F1 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: "I certify that in the performance of the work for which this permit is issued, I shall employ_personssubject to workman's compensation laws of California." The applicant must_call for all required inspections. Complete drawing on reverse side. 1 Signed X I&% Title: Daae:411 FOR DEPARTMENT USE ONLY Application Accepted byOr �ww Area �j Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by n Date + L Tracy 835-6385 Applicant - Return all cop to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. .Box 2009, Stk'., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ! INFO ! Li 5 0 EH 13-24 REV. 10/82 10/82 500 ! ' 14-26 �,