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w APPLICATION FOR PERtM!T VJ SAN ]OAQLiN LOCA! HE4LTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.�S �7 Telephone (209) 466-6781 DATE ISSUED -5-t5 r PERMIT EXPIRES I YEAR FROM DRTE ISSUED 7— (Complete in Triplicate) i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein f described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump I and the Rules and Regulations of the San Joaquin Local Health District, .�fl�r-,P•-7 Job Address Subdivision Name 'T► Q Owner's Name Address Contractor's Name nse No. Phone Zc TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 46k) _ SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial J, ❑ Open Bottom t&Manteca Dia. of Well Excavation ti U Domestic/Private ld Gravel Pack [J Tracy Dia. of Well Casing a 1' Publicl Del eta "~ U ❑ Type of Casing ~,S� V Irrigation . ❑ Eastern Specifications ❑ Cathodic ProtectioCWDep Depth of Grout Seal❑Geophysical A( Y Type of Grout ❑Other e x 'jx Surface Seal Installed by r Repair Work Done ❑ Type of,Pump H:P: State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') —, y Depth i Filler Material„ (Below 50') fit' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other I Number of living units Number of bedrooms Lot size t Character of soil tocafdepth of 3 feet: . . Water table depth k ' No. Compartments SEPTIC TANK ❑ Type/Mfg _~, Capacity P PKG, TREATMENT PLT. Typ{e/Mfg Capacity Method of Disposal k SEWAGE SYSTEM w Distance to nearest: Well ri. Foundati.on-._ -,-..T- .Proper.ty,L.ine_ f DESTRUCTION ( Total length/size I i LEACHING LINE U No.I j& Length of lines L.,I•`�'.. � 9 / FILTER BED ❑ Distance to nearest: Well Foundation Property Line1 . SEEPAGE PITS ❑ Depth Size dumber SUMPS L,j Distance to nearest; Well Foundation Property Line Y DISPOSAL PONDS ❑� 0 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 Iicensed.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. 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." s The applican us c I fog 1 required !inspections. Complete drawing on reverse side. Signed X Title: Date: v FOR P MENT USE ONLY c .�- "' +• Application Accepted by :: Area - f `❑ •Stk466`.6781 �x Additional Comments: ❑ Lodi 369-3621 ° Pit or Grout Inspection by Date ❑ Manteca 823-7104 1 ^" Y :. Final Inspection by Date •`y ❑ Tracy' 835=6385'i '' Applicant - Return all copies To:-'�tn"v.."-.-,-..tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY AT ' PERMIT NO:-7E�T I INFO . 10/82 500 Eh 13-24 REV, 10/82 14-26