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f..oU . APPLICATION FOR PERM;T p f / SPN JOAQUiN LOCAL HEALTH DISTRICT p� w 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. C� �� 0 Telephone (209) 466-6781 -7 44 -� DATE ISSUED �(� � [�"0,.� 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 Address Subdivision Name Owner's Name Address // �7�1/rl� f3i► ad Phone l �1 —�— Contractor's Name �fAV 0��l�i ham- License NO, c&�C��.� .. ' Phone��7� g TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION�> SYSTEM REPAIR �. OTHER U 1 i DISTANCE TO NEAREST:,SEPTIC,TANK.- �'�..� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS c>i Industrial ( Open Bottom Manteca Dia. of Well Excavation `(Domestic/Private Gravel Pack Tracy Dia. of Well Casing r E•ti V ( �] Public [Other Delta e of Casing YP jee,- T 1 'V Irrigation """ + ' ® A rox. Eastern 1 Depth Specifications � �° ✓� Cathodic Protection 1 F-1 Depth of Grout Seal Geophysical ' Type of Grout 9 -->,a il U Other a Surface Seal Installed by f JQ�`j�y 'Repair Work Done D''Type`of"PumpJ ', _ H.P . State Work Done #,. 'Well Destruction U Well Diameter Sealing Material (top Q50 ) �7 Depth Filler Material (Below 50') - { w TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/.ADDITION J (No septic tank or seepage pit permitted if public sewer is I c..._ -. a`^^'^.^*^-,�,"Y. - - -.+ T •"- .. -• ^^.^...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 ❑ No. & Length of`;lines Total length/size F . FILTER BED 17 Distance to nearest: 'Well Foundation. Property Line SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS D 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 performahce.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." - The applicant must call for all required inspections. Complete drawing on reverse side. j Signed X �, 41&A Title.: /"(e /��'�Q< Date: OR DEPARTMENT USE ONLY Application Accepted by Area Stk 466-6781 M ..d Additiona Comments: Lodi 369-3621 Pito Grout` nspection by Date i��_/7s Manteca 823-7104 VFinal Inspection by' Date - -- 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 DATE PERMIT NO. INFO _ _ EH 13-24, REV. 10/82 10/82 500 14-26 f