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APPLICATION FOR PERMIT 3-SAN JOAQLi^� LOCAL HEALTH DISTRICT ivp 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. '9300 - Il�� Li Telephone (209) 466-6781 ,i.P_li_ DATE ISSUED -1 'I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t 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 Prdinan a No. 549 for sewage or No. 1862 for well/pump cA o(„1 and the Rules and Regulations of the San Joaquin .Local Health Djd W Job Address 4 C t 2 Subdivision ame - Y Owner's Name i Address 3 G-il.� '� ✓�� Phone _ Contractor's NaLicense No. Ce C Phone d TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ $ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES i�+`ZS'"`�— DISPOSAL FLD. �� - PROP. LINE FOUNDATION �j�� — AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Indus ial ❑Open Bottom ❑ Manteca Dia. of Well Excavation omestic/Private [1�.6r3vel Pack ❑ Tracy Dia. of Well Casing G f Public Other Delta ❑ C1 ❑ Type of Casing ,�!.5-% Irrigation Approx. ❑ Eastern Specifications r ❑ Cathodic Protection Depth roDepth of Grout Sea ❑Geophysical Type of Grouta1 Othe � -� L-� r Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. /Z State Work Done Well Destruction ❑ Well Diameter 7 Sealing aterial (top 50') , Depth 7 Filler Material (Below 50') t `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 ri 1 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 SYSTEMDistance to nearest: Well Foundation Property Line S DESTRUCTION ❑ LJp LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPS ❑ 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 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 is permit is issued, I s ploy persons subject to workman's compensation laws of California." licant must cal r 11 r quuiiregd inspections. Complete drawing on reverse side. igned t� ..�r--� Title: u Date: (�.�-L�--- DEPARTM EN SE ONLY TAppl*cation Accepted by Area ? ❑ Stkl Comments: Lodi 369-3621 out Inspection by Date Q -\ Manteca 823-7104 Final Inspection 6TZL 6 `A Date Zg7g1 # ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. L4 INFO EH 13-24 REV. 10/82 �1 �1 _ �� L ^}' "t 10/82 500 14-26