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�-1b APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Y3-96�5 Telephone (209) 466-6781 l DATE ISSUED PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete it Triplicate) 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 No. 549 for s age r N 18 for well/pump and the Rules and Regulations of,th�e`5�' Joaquin Local Health District./��fs SGc}(�jh a} ,6 Job Address JJ M V &_6 Subdivision ame r O Owner's Name & Address P hN,e Contractor's Name License No. Phone41,o 1— -5 C10A TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION JV SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK �p (} SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL `� t _ OTHER WELL PITS/SUMPS INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� Industrial ❑ Open Bottom F Manteca Dia. of Well Excavation !] �� [�_;Omestic/Private Gravel Pack 0 Tracy Dia. of Well Casing e— -6 " _ 7 Public ❑ Other ❑ Delta irrigation Type of Casing E_i g Approx. [] Eastern Specifications (OR c� F—ICathodic Protection Depth Or 7 Geophysical Depth of Grout Seat Q jJ Other Type of Grout �'le L411 go Lot Surface Seal Installed yIdG Repair Work Done ❑' Type of Pump H.P. C�L State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION D (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other l Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK [j Type/Mfg Capacity No. Compartments PKG, TTMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE YSTEM Distance to nearest: Well Foundation Property Line DE RUCTION ❑ LEACHI LINE ❑ No. & Length of lines Total length/size FILTER 8 Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS Lj Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS CI I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county y 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 workmant 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 applica st call for all r ire inspect' ns. Complete drawing or reverse side. / Signed X Z Title: Date: F ?DEPA TENT U$E ONLY 04 Stk 466-678 Ap iCation Accepted y s Area Additional Comments: Lodi 369-3621 Pit or Grout Inspection b Date T 4;�—i Manteca 823-7104 M Final Inspection by Date L7 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. rNFo EH 13-24 REV. 10/82 ^�� e.—oN",e <.vs /�l �� /82 soo 14-26 .75J 17%air