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ANNED APPLICATION FOR PERMIT SAN JOAQU'iN LOCAL HEALTH DIST, Ail S i 1501 E.-HAZELTON AVE., STOCKTON, CA PERMIT NO. g Telephone (209) 466-6781 11 At �;�t�=) .st't-.��l�� O��i�DATE ISSUED�� PERMIT EXPIRES 1 YEAR FROM DATE ISSU D'i1EALTH DISTRICT (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 f the San Joaqui..9,�o�al Health District, Job Address �Q Ia, Subdivision Name c� Owner's Namey E iQ11r Address SAM f— Phone r— Contractor's Name L. 0,Q AJ -c License No, 12 r79010 Phone 6Mn2a?o7 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [j DESTRUCTION 0 .PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE ''•q FOUNDATION �,'kAGR-[CULTURE WELL OTHER WELL PITS/SUMPS i, . r . INTENDED USE TYPE OF WELL . PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ' V "1❑'Open Bottom �"?❑ Manteca Dia. of Well ;Excavation DomestielPriyate ❑ Gra.vel�Pack. t ❑ Tracy Dia. of WellCasirg Public �j Other ❑ Delta Type of Casing 71 Irrigation Approx. [] Eastern El Cathodic Protection �,I -`� Depth Specifications Depth of Grout Seal ❑ Geophysical °+ Type of Grout Other Surface Seal;Installed by Repair Work Done Type ofpump a.s H.P. I State Work Dane teimyu.Q Well Destruction U Well Diameter ,`, Sealing Material (top 501 _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑l REPAIR/ADDITION J (No septic tank.or seepage pit permitted if public "sewer is _ - ? available within 200 feet.) Installation will serve: Residence Cummercia '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 o Distance to nearest: Well Foundation i Property Line DESTRUCTION LEACHING LINE Lf No:°""&'L'ongth-of^hi nes----------•��----�---'`^-`�-Total -•length size .FILT,ER BEDa �._.,Y� ❑j �;D stance to nearest: Well Foundation i Property Line SEEPAGE PITS ❑ Depth Size Number il 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 is compensation laws Df 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 applican mu t,. 1'1"for��-_r�ed _ inspections.. Complete dr Ing on reverse side. �/ p' Signed X Title: Date: � A � ND FOR DEPARTMENT USO Application Accepted by � Area 04-- _ ❑ Stk 456-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspectio by Date Marteca 823-7104 Final Inspection by Date Lf- LI Tracy 835-6385 Applicant - Return al -1 copies to: vironmental Health Permit/Services 1601 E. Hazelton Ave. P.O. Box 2009, Stk., CA 95201 FEE I BASE AMOUNT DUE AMOUNT REMITTED INFO ;GANDOWN RECEIVED BY :1 DATE PERMIT NO. EH 13-24 REV. 10/82 -�'Lk 14-26 10/82 500