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I k APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (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 Ordinance No. 549 for sewage or No. 1862 for wel3/pump Y and the Rules and Regulations of th San Joaquin Local Health District. If! Job Address 6 1-IS V 6 Subdivision Name ' Owner's Name W-H. GRIah4oy Address Contractor's Name 'q(Z&t Phone License No. 9/8 Phone ' 39' 2 124 TYPE OF WELL/PUMP WORK: NEW WELL El WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial 0 en�Bottom �U. P .,,,.,, Q—Manteca. Dia..Mo•fxWell-Exca.vation f U Domestic/Private � Gravel Pack Trac E \ f ❑ Y Dia: of Well Casing I Public Ej Other Delta Irrigation Type of Casing Approx. Eastern M Cathodic Protection Depth ,, Specifications f D GeophysicalDepth of Grout Seal LJ Other a ! Type of Grout r � Surface Seal Installed by Repair Work Done ;Type of Pump H.P. �, State!Work Done Well Destruction U Well Diameter Sealing Material (top 50') I,11 ! Depth Filler Material (Below '50'} w � I TYPE OF SEPTIC WORKc11 NEW INSTALLATION REPAIR/,.ADDITION U (No septic&tank or seepage pit permitted if public sewer is f Installation will serve: Residence _ Commercial Other i' f� " available within 200 feet.) 1 Q r Number of living units: Number of bedrooms �_ Lot size ;10- AC."; Character of soil to a depth of 3 feet: ' ` Water table depth SEPTIC TANK ,t Type/Mfg PrZecA Capacity 00 /,No. Compartments u PKG. TREATMENT PLT. 0 Type/Mfg ` Capacity Method of Disposal SEWAGE SYSTEM i4 . —#- k Distance to nearest: Well U . DESTRUCTION �.a,CI Foundation _ Property Line LEACHING LINE' No. & Length of lines "' ?Cs' z}! Total length/size FILTER BED Distance to nearest: Well . _ Foundat-ion"s Property Line a SEEPAGE PITS 1 DepthSize _ �d Number SUMPS E U Distance to nearest: Well; Fouhdation Property Line DISPOSAL PONDS ^ �� i I hereby certify that I have prepared this application and that the work will be done 1n 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 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 became subject to workmanis compensation laws of California." Contractor's hiring or sub-contracting ignature certifies the following: "I certify thaf-in the performance of the work fpr which this permit is issued, I shall employ p rsons subject to workma201s compensation Taws of Cafifornyia" " t The applicant-"Ercall call f allequir inspections. Complete drawing an reverse side. r i Signed X �►+`• Title: �_ . Dater OR DEPARTMENT USE ONLY }..-�...-_ Application Accepted by �,� - Arear~` Stk 466-6781 Additional Comments: 5.,� 'atfj; Lodi 364-3621 Pit or Grout Inspection by } Date! Manteca 823-7104 i Final Inspection by Dater s_ .„L Tracy 835-6385] Applicant - Return all copi o. . Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, St k., CA ,95201 FEE BASE AMOUNT DUE AMOUNT REMITTED ( RECEIVED BY! DATE PERMIT N0. INFO � ! r�r ,..__ r...._._.:....�.,,.,�,��...-:,..:R.._.w:.�.-a-- _. ---�-.�y..,wW1wb .�:..rr..,r.c • '^'..Si-��CS'� �..,.,g^_do f - � wM.... k 1 EH 13-24 REV. 10/82 d . 14-26 c _ �e€` =tTw '�10/82 500