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APPLICATIO9 FOR PERMIT APR 2aI SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 F. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466,6781 SAN JOAQUIN LUCK; �� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUE HEALTH DISTRICT, (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 described. This application is made in compliance with San Joaquin County Ordinance No. 549 fer sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address 1216' �i � [ OAI— Zp ivision Name Owner's Name D uw is Address nn 6L Phone 6,36—.5 760�► Contractor's Nam e ®jf () License No, ��]�}(�/� Phone � (l TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR i OTHER DISTANCE TO NEAREST:._SE.PTIC.,iANK SEWER LSNESDISPOSAL TLD. PROP. FOUNDATION AGRICULTURE WELL . OTHERIWELL r' ` PITS/SUMP,S• INTENDED USE TYPE OF WELL F PROBLEM AREA CONSTRUCTION S[JECIFICATIONS I—J Industrial U Open Bottom D Manteca Diad of W61'1-Excavation Domestic/Private Gravel Pack Tracy Dia: of Well Casing t � k Public L ether Delta Type of Casing Li Irrigation Approx. Eastern `a 4' ' •'�� Depth specifications Cathodic Protection Depth of Grout Seal Geophysical, . Type of Grout Other. _ s Surface Seal Installed by S Repair Work Done' t Type of Pump "' H.P. State Work Done WW__,F405 Wei l.'Destruction U?a Wel..] Oiamefen_*w . .. - Sealing Material (top 50'} Depth Filler Material (Below 50!,) ,r O r ---TYPE OF SEPTIC WORK: NEW INSTALLATION-U. REPA-IR/-ADDiTION LF.(No septic tank ..oF seepage pit.permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other I �k Number of living units: Number of bedrooms Lot size. 5 . Character of soil to a depth of 3 feet: V Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation! Property Line DESTRUCTION Q LEACHING LINE J No. & Length of lines (Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS a Distance to nearest: Well Foundation' Property Line �? DISPOSAL PONDS ❑ 1 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'�hl 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." Contractor's hiring or sub-contracting signature certifies the following:'F"1 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." i. The applica ust 11 for 1)l re ed inspections. Complete d/raJ�g on reverse side. Signed X Title: ! SLB Date: i4 R ARTMENT USE N �! ❑ Application Accepted by �✓ Area : �` Stk 466-6781 Additional Comments: Lodi 369-3621 ; Pit or-Grout-I•nspection by; t. � 1 Date Manteca 823-7100. Final 'Inspection bye` �" Date `� N L Tracy 835-6385 Applicant - Return all copies t Environmental Health Permit/Services 1;601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 ��Q 10/82 500 14-26