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APPLICATION FOR PERMIT SAN JOAQU;,; LOCAL HEALTH DISTRICT _ 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 474� GATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate) A pplication is hereby made to the San 'Joaquin Local Health District for a permit to construct and/or install the work herein This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump Rules and Regulationsothe..San Joasluin Local Health District. ress L Subdivision Name Name �r Contractor`s Nam 17w1ze�se No. 2 Phone TYPE OF WELL/PUMP WORK: NEL! WELL �] WELL REPLACEMENT � DESTRUCTION ❑ (`� PUMP INSTALLATION SYSTEM REPAIR OTHER i1 v'. ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES * ) OISP05AL FCD. PROP. LINE f FOUNDATION — AGRICULTURE WELL OTHER OTHER WELL PITS/SUMPS �' "��INTENDED USE f TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS^ �J Industrial U Open Bottom ❑Manteca Dia. of Well Excavation— Domestic/Private xcavation— Domestic/Private Gravel Park Tracy Dia. of Well Casing Public Other '" 4 a TYPe�of Casings �_ f Li Irrigation ti�Approx. ] Eastern d Specifications r. v---Ga�thod�ic-Protert-ion----� Depth i c Depth;of,.Grout,Seal ''A I Geophysical t r r'!b *' Type of Grout �:• - { U Other /ate ! ' ) Surface Seal 'InstalIed b f aR # o + y Repair Work Done Type.-of Pump K.P. State Work Done 'r 1 _ s 1 _ Well Destruction.UJ�Wel lfD.iameter _ Sealing Material (top 50') 1 Depth 1 Filler Material {Below 50'))^ _ ti TYPEtOF SEPTIC_WORK:_-N _INSTALLATION [ REPAIR/ADDITION ❑ (N� septic 'tank or seepage pit permitted-if public sewer is IJ f I ,� -available within ;200 feet.) ! Installation will serve: Residence Coercial X_ Other �' Commercial Number of living units: Number�o b Brooms --- — Lat`size x `Y 7 Character of soil to a depth of 3 feet: _ n _�.=- ' Water table depth G t ' Ca acity p No. Compartments rn SEPTIC TANK �f Type/.idfg e P -- ------- PKG, TREATMENT—P-L-T-M�pe/Mfg Capacity Method of Disposal ' �� Propert Line +SEWAGE SYSTEM Distance to nearest: lde]1 Foundation -- P S � DESTRUCTION LEACHING LINE [ f 'No. & Length of lines D Total length/size fig FILTER BED 17 Distance to nearest: Well vundation 1 0 Property Line ` 33 f SEEPAGE PITS { Depth Size !�er r SUMPS LJ Distance to ne rest: Well Foundation + �prp,�rtyLin, DISPOSAL PON65 � � ;r I hereby certify that I 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 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 permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." e of the work for which Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performanc this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicanr7NSt call .1. r al equired inspections. Complete drawing gn�erse side. S Signed X iC.� Title: Z Date r FOR DEPARTMENT USE ONLY E] 5tk 466-6781 Appli ation Accepted by,, Area Additional Comments: Lodi 369-3621 Pit or Grout Inspectifio,.: t Date U Manteca 823-7104 Final Inspection by Date L Tracy 835-6385 Applicant - Return all copienvir- nmenta Health Permit/Services 160 �F , on Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT RFMITTFD RECEIVED BYjF� PERMIT N0. INFO t 10/82 Soo EH 13-24 REV. 10/82 14-26