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x r APPLICATION FOR PER , r: ? SP.N JOAQlii"1 LOCAL HEALTH DISTRICT " 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. -9q q 7 h- Y Telephone (?09) 466-6781 ., DATE ISSUED i - PERMIT EXPIRES 1 YEAR FROM,DATE ISSUED'' (Complete in Triplicate) _, t, 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 Na, 549 for sewage or No. 1862 for well/pump and the RulAName tions of kSa '0<1quinLocal Health District._Job:Address bdivision Name phone Owner's Namddress E Contractor' License No. �- Phone eJ �.�lF TYPE OF WELL/PUMP WORK: NE4! WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAhR LJ 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 '►� -{� J Industrial U Open Bottom ❑ anteca Dia. of Well Excavation Dourest-ic/Private.. Gravel Pack 3 Tracy Dia. of We11-Casing .. .....� _,_.,: v.� ,, - Public ther Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications III ❑ Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ° State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below TYPE OF SEPTIG WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) 4 Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size C I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑V Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. f_1Type/Mfg Capacity Method of Disposal "•. �. SEWAGE SYSTEM Q Distance to nearest: Well Foundation Property line , DESTRUCTION + LEACHING LINE ❑ No. & Length of lines. Total length/size + FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number F SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .' -x '"" I., I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county F ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. { fies the following: "I certify that in the perfo Home owner or licensed agent's signature certirmance of the work for which this ot employ any person in such manner as to become subject to workman5 compensation laws of California." permit is issued, I shall n Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is i ued, I shall employ persons subject to workman's compensation laws of California." The appli must cal for 1 required inspections, Complete drawin n reverse side. • Title: Data: Signed — a E U Q ❑ Stk 4fi6-6781 Application Accepted by �/� Area �_ �_ --� ❑ Lodi 369-3621 Additional Comments: - ❑t'+' Date Manteca 823-7104 p or Grout Inspection b Date ��acy 835-6385 .Final Inspection by AM . — �Tr a w - tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k.,'CA 95201 Applicant Return all,copies to: Environmen n FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO r - '7 / ` 0/82 500 . EH 13-24 REV. 10/82 14-26 r• G ,-