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j ! � APPLICATION FCR PE'F.!7 SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. 1601 E. HAZELTON AVE"4STOCKTON, CA i Telephone (_0.) DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) in n B ance with San Joaquin County Ordinance No. 549 for sewage or Na. 1862 for well/Pu Application is hereby made to the San Joaquin Lacal Health District for a permit to construct and/or install the work erell described. This application is made in comp ` and,the Rules and Regulations of the San Joaquin Local Health District. �� Subdivision Name �"nT phone Sob Address E Address Owner's Name r.. � Phone t�f! �—��7/ License No. Contractor's Name - WELL REPLACEMENT ❑ DESTRUCTION ❑ W I TYPE OF WELL/PUMP WORK: NEW WELL ; ❑ OTHER ❑ }' UMP -NST�ALLAT-ION ON -PAIR L PROP, LINE _ DISPOSAL FLO. SEWER LINES PITS/SUMPS 0 4 DISTANCE TO NEAREST: SEPTIC TANK � OTHER WELL FOUNDATION AGRICULTURE WELL { CONSTRUCTION SPECIFICATIONS _INTENDED ED USE TYPE_ OF WELL _PROBLEM AREA t 10 Industrial U Open Bottom ❑Manteca ` Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑Gravel Pack [}Trac y , ❑Other ❑ Delta Type of Casing ❑ public Eastern P Specifications Depth Approx. ❑ Depth Depth of Grout Seal FJ Protection i i �,, „,,, - — ❑Geophysical I Type of Grout I Other Surface Seal Installed by iType +H P t State Work Done Repair Work Done ❑ of Pump �� 50') Sealing Material (top Well Destruction ❑ Well Diameter �_.� n , Depth- rt• ''Filler+Material (Below 501) 3 REPAIR/ADDITION No septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK- �.NEW.�INSTALL�AJTION�❑ available within 200 feet.) / Commercial Other installation will serve: Residence E ® k Lot sized J .i Number of bedrooms Number of living wits: _ Water table depth Character of soil to a depW of 3 feet: Capacity . No. Compartments T e/Mfg w SEPTIC TANK �1 yp Capacity . Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg Foundation Property Line ' Distance-to nea er st: Well SEWAGE SYSTEM i DESTRUCTION Total length/size No. �& Length of lines k LEACHING LINE Foundations Property Line FILTER BED ❑6. Distance to nearest: Well Number / Depth __ Size SEEPAGE PITS Foundation property Line SUMPS LI_Distance to nearest: Well ofALA DISPOSAL PONDS �} 1 hereby certify that 1 have prepared —application and that the work will be done in accordance with San Joaquin county "I certify that in the per of the work for which this ordinances, state laws, and rules and regulations of the San Joaquin Local Health in the . Home owner or licensed agent's signature certifies the fallowing: „I certify that in the performance of the work for which i permit is issued, I shall nat :employ any person in such manner as to became subject to workman Compensation laws of California.' he Contractor's hiring or sub-contracting. ersonsure subjectltoest I an'slcompensation laws of California." this permit is issued, I shat l employ=p Complete drawing on reverse side. ections. Comp 9 The applicant must call for all required sp Date: _ - ,.:Y Title: Signed X ❑ 46b-fi781 F R DEPARTMEN SE ONLY Stk Area � Application Accepted by �i✓ ❑ Lodi 369-3621 Additional Comments: Date r �,F� ❑ Manteca 823-7105 t ;Inspection by �/ ❑ Tracy 835-63$5 Pit or Grou f , "s Date �� / Final Inspect kion by Applicant - Return dll co e to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95 DATE FEE PERMIT NO. AMOUNT REMITTED RECEIVED BY FEE BASE AMOUNT DUE. INFO 3 J `^ -Q 3 10/82 500 EH 13-24 REV. 10/82 1 14-26 _