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APPLICATION FOR PERMIT g- 6 SAN JOAQUIN LOCAL HEALTH ISTRI�T,; 1983 1601 E. HAZELTON AVE.,AVE., STOCKTON,LCA� 1�I �r 1983 PERMIT NO. � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE�'e ,�'a . ' -{ 3 � LOCA DATE ISSUED (Complete in Triplicate) HEALTH DISTRICT 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. �or,sewage or No 1862 for well/pump and the Rules and a tion of the an oaquin ocal Health District. Job Address S 2ubdivi Name 7 Ifn Owner's Nam cc t Phone .Z"' 46 .Z. Contractor's Name I& License No. 2,3 7_3 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE T)-,E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ?o-pen Bottom F-1 Manteca Dia. of Well Excavation U Domestic/Private F-1 Gravel Pack F_� Tracy Dia. of Well Casing Public Othe Delta Type of Casing �jIrrigation pprox. 0 Eastern Specifications ❑ Chodic Protection Depth atroecon Depth of Grout Seal 1-1 Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done [J Type of Pump H.P. State WorkDo Well Destruction Well Diameter � Sealing Material (top 50') � � l�J 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 TANKType/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 LJ Distance to nearest: Well Foundation Property Line 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 ordinances, state 1 and rules and regulations of the San Joaquin Local Health District. Home owner or 1' ensed ag is signature certifies the following: "I certify that in the performance of the work for which this permit is is ed, I shall n t employ any person �rtifimes such anner as to become subject to workman compensation laws of California."i Contractor' hiring or sub- ontracting i n to the followin • "I certify that in the performance of the work for which this per mi is issue I 1 emp y s ct workman's co a sation laws of Ca ifornia." The appli ant m f all ection . Complete dr on reverse Signed X Title: Date: *4&3 p �R/T�MENT USE Application Accepted by GKi�1'�� rea Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by - Date`"�d ❑ Tracy 835-6385 Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY (� QDATE PERMTNO�.INFO �3 y �3 10/82 500 EH 13-24 REV. 10/82 14-26