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' APPLICATION FOR PERMIT rd� ��SAANJOAQUIN LOCAL HEALTHDISTRICT "�iE. HAZELTON AVE.,ST.00KTON, CA�� Telephone (209) 466-678) PERMIT NO. 7 C GCS ,- ER IT EXPIRES I YEAR FROM GATE ISSUED DATE ISSUED ;. (Complete in Triplicate) App] ication is hereby made to the San Joaquin Local Health District`fvr a permit to construct and/or install the work herein described. This application is made in compliance with San Joaqu Aiane- Owner's nan a o, 549 for sewage or No. 1862 for well/pump •' and the Rules and Regylations of the San Joaquin Lo al _H€al i rY3D Job Address �'A $u Name Address Phone Contractor's Nam cense No. -- -4. Phone TYPE OF WELL/PUMP WORK: N1 WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ G 4'0 PUMP INSTALLATION .SYSTEM REPAIR �. OTHER DISTANCE TO NEAREST: SEPTIC TANK } �'/ SEWER LINES a� t{]./ ' t pISPOSAL FLD./ d 0 FOUNDATION OTHER•WELL �RO S �`iel,e� ) LIN r AGRICULTURE WELL w.�. PI /SUMPS.._ INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial -_U Open Bottom Manteca 0 Dia: of Well Excavation Domestic/Private ❑ Gravel 'Pack Tracy--- ❑ Y Dia. of Well casin ❑ Puti,lic� w Other 16. k g� Dg Irrigation s `_ ❑ Delta ��. Ty Pe of Casing Approx. � Eastern Cathodic Protection Depth Specifications GebphysicaI — Depth.of..Gro`it-.Seal Q ❑ Other "' Type of Grout (iSurface Seal�lnstalled by -,Repair Work Done ❑ Type of Pump H. P. Y State Work Done s '� Well Destruction U Well Diameter sealing Materiali(top 50;)" Depth Filler Material (Below_50�), -, ��• TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet.) `Number of living units:' Number of bedrooms Lot size r ' CFiaracter-ofysoiT..to a depth of 3 feet: Water table depth SEPTIC TANK [j Type/Mf g Capacity NO Compartments [ # PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposa.l.- SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line. DESTRUCTION ❑ LEACHING LINE U No. & Length of lines Total length/s-ize [ A FILTER BED ❑ Foundation _ Property Line a Distance to nearest: We11 i r� r SEEPAGE PITSth De ❑ P Size Number $' SUMPS U Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ` -1 `� I s I hereby certify that I have prepared .this application and thatthework will be done in accordance with San Joaquin�countyf ordinances, state Taws, and rules and regulations of the San Joaquin LocaliHealtli 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 toworkman§ compensation laws of California." Contractor's hiring or sub -contracting signature certifies the following:Vlicertify that in the performance of the work for"which this permit is issued, I shall employ persons subject to'workma'.s compensation laws of California." The applic nt st call for all uire inspRcjRTM2NT ns. CompleteAddring'on reverse side./ Signed �oplication ,Title: Date: FOR DE USE ONLY Accepted by `� Area Z1 [] Stk 466-6781 9 ,F Additional Comments: r ; Lodi 369-3621 Pit or Grout Inspection by Datev T� Final Inspection by I Date i ❑ Mahteca 823-7104 L Tracy 835-6385 Applicant - Return all copies to:, Environmental a7th Permit/Services 1601 E. Hazelton P.O. Box 2009, Stk., CA 952011: FEE BASE AMOUNT DUE 'AMOJNT REMITTED RECEIVED BV RATE PERMIT N0. INFO - _3_mss l _.. r EH 11=24"""`REV710/82 .....t_.- .._.... �,.�..._,_.»..-- - -. :�' � _,0 8 . 1 / 2 500- 14-26 �. - t