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APPLICATION FOR PERMIT r SAN JOAQUiN LOCAL HEALTHf5ISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 Q �3 " PERMIT E;(PIRES 1 YEAR FROM DATE ISSUED 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 Jo a uin Local Health District. Job Address W ArAw Ir Subdivision Name Owner's Name JVV Address "' Phone � Contractor's Name ��1Q License No. lmsaPhone 1913 �� TYPE,''OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTIONjJ PUMP INSTALLATION SYSTEM REPAIR LJOTHER , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE ( \ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE "�`' `o"` s I ( TYPE OF .WEL"L PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� Industrial I " Open Bottom Manteca Dia. of Well Excavation jJ Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public G Other Delta LjIrrigation Eastern Type of Casing � ��." ^ Approx. . -ti� Specifications t [j Cathodic Protection Depth . {n I—]Geophysical Depth of Grout Seal LJ \; K Type of Grout Surface SeallInstalled by Type of Pump X p Repair Work Done [j ', H.P._ State Wo XiDone Well'Destructicmn Well piame:ter, Sealing Material (top 50') _ Depth Filler Material TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AGDITION Lf (No septic tank or see a pit permit ed if public sewer is I )av ]able within 200 feet.) Installation will serve: Residence - o°`^ '_� Commercial Other d Number of living units: Number of bedroLot size �j✓.— Character of soil to a depth of 3 feet: ` ' N Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg t, Capacity Method of Disposal I t SEWAGE SYSTEM ��--1l `^•-p 'stance 'toln6ar.est-1 el l Foundation Property Line DESTRUCTION LEACHING LINE ''j ''\No. &"�Leigth of lines Total length/size d FILTER BED ❑ Distance to nearest: Will Foundation Property Line k SEEPAGE PITS F—j Depth t Size Number i SUMPS �j Distance to nearest: I Well Foundation � ,Property Line i _L4 DISPOSAL PONDS i I hereby certify that I have prepared this applica`t'ion and that the work will be done in accordance with- San Joaquin county ordinances„state laws, and rules and regulat"io`ns"of the San Jvaquin_„Local__"Health District. Home owner or licensed agent's signature cert f.ies'the following:' "I certify thatin the performance of the work for which this i permit is issued, I, shall not employ any person in ;such"manner asito become subject to workmant compensation lawO of""California." Contractor's hiring or sub-contracting signature ce.r-tiiwies 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. r � s Signed X .1� j '. F Title: # ,�1�iar/ff� _ _ Date: F { MENT USE ONLY .' s Application Accepted by ` Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection y Date Manteca 823-7104 FinalInspection by �y,L� f Date {►`�J Tracy $35-6385 " Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk!, 'CA 95201 i 3 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY. DATE PERMITJNO.. -INFO=, _ t ` ti -�•.-.s-.,�...,.�..-.,.o.�..�-"._.�-� „-�,-..bj EH 13-24 REV. 10/82 14-26