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- I APPLICATION FOR PERMIT SRN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELj_ON 4VE„ STOCKTON, CA PERMIT NO. Telephone_(209) 466;6781 DATE ISSUED i PERMIT EXPIRES I 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 Regulation Of a Joaquin L al Health District, Job Address Subdivision Name1 Owner's Name Il Address Phone Contractor's Name License No. y Phone ` -f(2, } TYPE OF WELL/PUMP WORK: NE4! WELL p _ELL REPLACEMENT DESTRUCTION r 7 PUMP INSTALLATION SYSTEM REPAIR �. OTHER- LJ �r , . DISTANCE TO NEARES • SEPTIC'�TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4. f _ INTENDED USE I� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r J Industrial Open Bottom Manteca Dia. of Well Excavation Domestic/PrivateGravel Pack Tracy Dia. of Well Casing fel(:6F Public ;'Other [] Delta Irri ation �-�, »^—*.- �� TY Pe of Casing 9 [--- -. :Approx. ❑ Eastern A 1 Cathodic Protection Depth Specifications 4 U Geophysical Depth of Grout seal i Type of Grout f t F❑Other Surface Seal Instal ed by h Repair Work Done Type of Pump H.P. .,. '".. State Work Done I 01 ' Well Destruction j jQ Well Diameter. lI,+�Sealing Material (top 50') ./ � , �` l } s Depth 9 _ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is dO el ; A available within 200 feet.) 'Installation: wi 'I'rserve: Residence_ Commercial _ Other I -,Number of-l.i.v-ing .units: '- Number of bedrooms Lot size � w Character of: soil to a depth of 3 feet: Water table depth ype/Mfg4 �SEPTIC TANK Capacity No. Compartments PKG. TREATMENT PLT, 0 Type/Mfg Capacity Method of Disposal s! , ' SEWAGE SYSTEM Distance to nearest: Well `s Foundation Property Line k DESTRJCTION ❑ '�� . LEACHING LINE""'" '" U"`"N & Length of lines Total length/size FILTER BEDDN ystance'td'6eares,t.:.,,_Wel.l_-_ Foundation Property Line _ IT :F. SEEPAGE PITS `�j _ %Depth' i Size Number 4 46 t . SUMPS lstancL to nearest: Well Foundation 4 Property Line 1 DISPOSAL PONDS �� I hereby certify that,I have prepared this application and that the work will be done in,accordance with San Joaquin county j ordinances, state laws, and, rules and regulations of the San Joaquin Local Health District., ?- Home owner or licensedagent's signature certifies the following: "I certify thet 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 tal, fornia." The applicant st ca 1 all required inspections. Complete arawin on reverse slide. ��Sigie:d - § itle: �, ., /� Date: Y i F EPARTMENT USE-ONLY; Application Acc/ed!by Area a g Stk 466-6781 [ Additional'Commentsy f ' ' Lodi 369-3621 a' Pit ora Grout Inspect;kiv Date 7 / � Manteca 823-7104 Final Inspection by 1 Date ��— — Tracy 835-63$5 Applicant - Return all cap' to: . fnvironmental Health Permit/Services Al E. Hazelton Ave., P,.0. Box 2009,�Stk., CA 95201 FEE 'BASE--- MOUNT..DUE- - _ AMOUN7.REMITIED ., RECEIV.E_D ,BY. DRTEPERMIT NO. INFO TS.. _. _ [ LH 13-24 REV. 10/82 I - 10/82 500 14-26 I r.