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1 APPLICATION FOR PER',ii" SAN JOAQUi"ti LOCA_ HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM 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 described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address63IN/4C.P1A1E ?2:r>, -57Z7GAtf7-0 J Subdivision Name Owner's Name <i4,cAl 54FY7?,)A,1 Address 53T At, A-G_P/NE" T21D Phone l"3 . Z Contractor's Name<5/e2!jLJAL W,9& -Pi2/C.4/A//cense No. 3 37 0,'2-- Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR 1-1 OTHER U �Q DISTANCE TO NEAREST: SEPTIC TANK /J/0 SEWER LINES DISPOSAL FLD. PROP. LINE /O FOUNDATION AGRICULTURE WELL OTHER WELL 10'4- 4W/SUMPS Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z IJ Industrial JX Open Bottom []Manteca Dia. of Well Excavation �oZ�� ' J'C7� I Domestic/Private F�Gravel Pack [] Tracy Dia. of Well Casing g �� Public [—I Other F-1DeltaType of Casing SQL .t�1 Lj Irrigation A'� Approx. E] Eastern Specifications /'10 (5111r �'o Cathodic Protection Depth Depth of Grout Seal L_J Geophysical Type of Grout 9 !_Eil.1Ei1/7��40zo-T- Other Surface Seal Installed by G/j&-SoAl Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: 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 LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 workman1s 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 m t c 11r allrequired inspections. Complete drawing on reverse side. Signed X Title: it�t o-/`i}�C� Date: FOR PA SENT ?E ONLY Application Accepted by w, Area _ _ ® Stk 466-6781 Additional Comments: [� Lodi 369-3621 Pit or Grout Inspection by Date Z Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environme al Health Permit/Services 1601 azelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED �RlEyyC��EIVED BY DATE q�P/ERMIT NO. INFO 1473 �� NU it-Z7 EH 13-24 REV. 10/82 10/82 500 14-26