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` G APPLICATION.FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA -` Telephone (209) 466-6781- PERMIT NO. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' DATE 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 1 described. This application is made in compliance with San Joaquin County Ordinance No. and the Rules and Regulations of-the San Joaquin_ Local Health Dist549 for sewage or No. 1862 for well/pump rict Job Address . L✓/9 Subdivision Name Owner's Name SAND, Address Contractor's Name Phone icense No. iE Phone TYPE OF WELL/PUMP WORK. NEW WELL 10 WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ;2j SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK �� ` SEWER LINES4 DISPOSAL- FLD. �Dqc PROP. LINE I t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE .TYPE OF WELL PROBLEM AREA ' I CONSTRUCTION SPECIFICATIONS Industrial El Open Bottom Manteca ��41 ❑ Dia, of Well Excavation �'•Damestic/Private ravel Pack Trac Ti 17 Public � y Dia- of Well Casing [j Other Delta U Irrigation i` 71:20Type of Casing-� �.� Approx. �Eastern Cathodic Protection - Depth Specifications Q ❑Geophysical _ �; i ;. Depth of Grout Seal 529 U Other MI : Type of Grout C Q Tj= `Surface Seal Repair Work Done Type of Pump In�sta_lled by H.P. State /; WDonePl�,�i �L D�II�LI/4j Well Destruction EJ We11�Diameter� Searing Material (top 50') ` Depth Filler Material 50') f r*.�� TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION [J (No septic tank.or seepage pit permitted if public sewer Installation will serve: Residence _ Commercial 4 Other i available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil-tb a' d6pth of-3-feet:,..�,�.- ----- a '•-Water table depth f SEPTIC TANK ❑a Type/Mfg Capacity "s P y No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity SEWAGE SYSTEM Method of Disposal DiFoundation J Distance to nearest: Well DESTRUCTION ❑ � 'Property Line LEACHING LINE -No. & Length of lines Total length/size y FILTER BED Distance to nearest: I.Well Foundation Property Line .� SEEPAGE PITS Cj Depth' 'Size Number SUMPS •- ' U Distance to�nearest:�Well Foundation Property Line ' DISPOSAL PONDSell F, n 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'i�,compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." 'The applicant st 11 or all req fired inspections. Complete drawing on reverse side. Signed X"' 01 Title: �j` Date: h� F PA ENT USE ONLY - Application Accepted by Area 5tk 466-6781 Additional Comments: ' E] Lodi 369-3621 F I Pit or Grout Inspection by `'' 4. natW- , Manteca 823-7104 Final Inspection by Date _ Tracy 835-6385 1 w V Applicant - Return all copies to: EnvironmentalrHealth Permit/services n Ave P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT RECEIVED BY DATE PERMIT N0. — r INFO REMITTED `i EH 13-24 REV. 10/82 14-26 r 10182 500