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4 APPLICATION FOR PERMIT �� SAN JOAQL'iN LOCAL HEALTH DISTRICT z Jx� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466,-6781 ' 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 Joaquin Local Health District. Job Address 462 .Beit Rd.,, Subdivision Name Owner's Name Address T Phone Contractor's Name Moorman tWater b*ense No. Phone 931-32-10 TYPE OF WELL/PUMP WORK: NEW WELL- Xn WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 'SYSTEM REPAIR ❑ OTHER [J- DISTANCE 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 ❑ Industrial U Open-Bottom-�❑ Manteca Dia. of Well Excavation Ej Domestic/Privates. Gravel Pack ❑ Tracy Dia, of Well Casing I �� Public Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical g Type of Grout Other Surface Seal Installed by Repair Work Done E] !Type of Pump _� H.P. f State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') �} Depth Filler Material (Below 50') y IT " i�irrr. n wiuiun. wrr a�.....n.rnni:ni TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is 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 ;1 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS CJ Depth Size Number i 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 workman5 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 applic4_ st ca for Il required inspections. Complete drawing on reverse side. Signed X Title: �('^n�C��amrar 1 "' " Date:. . 7'^6""83 RARTMENT Application Accepted y .. Rrea ❑ Stk ` 466-6781 ; Additional Comments: 4d ❑ Lodi 369-3621 t Pit or Grout Inspection b Date ❑ Manteca 823-7104 final"Irrs ection b - --Tracy 835=6385-- p y'"`"" Date^r at .�_ Applicant - Return all copies to: Environmental Health Permit/Services 1601 L. 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 i