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APPLICATION FOR PEPMIT r SAN JOAQUiN LOCAL HEALTH DISTRICT t3 rqq r 1601 E. HAZNO ELTON AVE., STOCKTON, CA PERMIT . ' Telephone (209) 466-6781 DATE ISSUED - PERMIT EXPIRES I YEAR FROM D4TE 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 inance No. 454for sewage or No. 1962 for welly.pumpdescribed. This application is made in compliance with San Joaquin County Ord "andEthe Rules nd R u at' ns of the San Joaquin Loca��ea riot. Job Address = - i(tP.J Su ivision Name Ab z Owner's Name T Address Phone Phone ,�� Contractor's Name License No. TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U F DISTANCE;TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLD. PROP. LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I, INTENDED USE. _ _ I Industrial Open Bottor--- --'Manteca Well Excavation 111 U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing 4 i ❑ Public Other ❑ Delta Type of Casing Lj Irrigation Approx. Eastern Specifications II Cathodic.,Protection Depth S Depth of Grout Seal S ❑Geophysical Type of Grout � r ❑Other; Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done s .Well Destruction ❑ Well Diameter Sealing Material (top 50'.) s w r Depth Filler Material (Below 50') l I { TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION J (No septic tank or 'seepage pit permitted if public sewer is I ,,--� available within 200 feet.) I ` Installation will serve: Residence ommerciai-4_*, Other L� - I-ot-size - �. y� ' l Numberof living-units: =----Number of-bedrooms —�` F �T Character of soil to a depth of 3 feet: _�QpG ��?'�' ' '' Water table depth Ca acity^�'- N6;�Compartments ; SEPTIC TANK p 1 Capacity 'f Method of Disposal PKG. TREATMENT ptT. [] Type/Mfg L Propert ne SEWAGE SYSTEM �y�1 -Distance-to-nearest:--W --Foundation :`_ y'Lu DESTRUCTION ALL } ; LEACHING LINE No. & Length of lines Total length/size W— l `Pro ert Lie FILTER BED QDistance to nearest.- Well - Foundation � .P y'"S SEEPAGE ITS Depth -tSize r Number '[ ism❑ SUMPS Distance to nearest: Well Foundation Property/L ne J h ro ` DSSPOSALI PONDS ❑ * r s f. " �" I hereby certify,;that 1 have prepared this application and that the work will`be done in, accnrdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heallh District. Home owner or licensed agent's signature certifies the following: "I certify tbAt`in-the 'performance of••the work for which this permit is i.ssued�I shall not employ any person in such manner as to become subject to workman§ compensation laws of California." i•' Contractor's hiring or sub-contracting signature certifies the fallowing: "I certify' in the performance of the work for which { this permit is issued, I,shall employ persons subject to workman's compensation laws of'California." e _. I. !The applicant must call requir 'inspections. Complete drawing on reverse side. i. � Date: Signed C { FOR.DEP MENT USE ONLY r 466-67$1 n Applicat ioAccepted; by i t ❑ Stk �~ ❑ Lodi 369-3621 Additional Comments:, ,r'; .. Date ❑ Manteca 823-7104 Pit or Gr :ib Grout lnspecton _ _ �....,. M. . ._Date j L Tracy 1 835-6385 Finll% fhspection by i Applicant -,Return all copies to: . EnVJro tal Health Permit/Services 1601 E. Hazelton e., P.O. Box 2009, St k., CA 95201 FEE r'BASE SUNT DUE €' AMOUNT DATE PERMIT N0. REMITTED - RECEIVED BY �} G T INFO 10/82 500 FH 13-24REVt. 10/82 14-26 . _