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v!.- 1 APPLICATION FOR,PER i t SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOC•KTON, CA PERMIT NO. Telephone (209) 466-6781 4 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 Joaauin.Local Health District. Job AddressAl Subdivision Name �� L Owner's Name ) Address als A-i ki.;a - ► Phone q Contractor's Name License No. G�[�_� �-� Phone��;-� ��. t,6 pd TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION W PUMP INSTALLATION � SYSTEM REPAIR �, OTHER �� 1 ,DISTANCE TO NEAREST:,,SEPTIC�TANK* M4_°..r'`s•.,SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ` PITS/SUMPS s _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C> 1f--] Industrial Open Bottom F-1 Manteca Dia. of Well Excavation "Domestic/Private EJ Gravel Pack Tracy Dia. of Well Casing 17 Public s F-1 Other 0 De to Type of Casing - f lf' 'V Irrigation V0� Approx. [] Ea tern Specifications C° ✓e�6 r �Cathodic Protection Depth Depth of Grout Seal ° Geophysical al' e Other Type of Grout ��x ��n 4 Surface Seal Installed by � ��jm 'Repair Work L,2u'Typeof'Pump H.P . State Work Done a % V r% UP f Well Destruction ❑ Well Diameter Sealing Material (top;50') 1 "� t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION F--1 REPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sewer is s".sR*�~ ". .�.* � _ ;"`-.. `. �-•• �~ - ^..�avai°lable 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 oe lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line 'i 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 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. 7 The applicant must call for all required inspections. Complete drawing on reverse side. Signed X '` ,-tea Title: �/ ��QC Date: OR DEPARTMENT USE ONLY Application Accepted by Area Lb-zl Stk 466-6781 �v Additional Comments: [] Lodi 369-3621 V Pito Grout' ns'ection by Date -06 /7- .r El Manteca 823-7104 Final 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 _7 EH 13-24, REV. 10/82 10/82 500 14-26