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APPLICATION FOR PERMIT +, SRN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, C ��// ERMIT NO, Telephone (209) 466-6781 DATE ISSUED {� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 18 1987 J (Complete in Triplicate) h I�tW VU40( �TH • Application is hereby made to the San Joaquin Local Health District for a be stall the work herein described. This application is made in compliance with San Joaquin County Ordin or No. 1862 for well/pump and the Rules n rReegulations(�f th San Joaquin Local Health District, i) 1 Job Address C J 1 V[N Subdivision Name Owner's Name { �{/ p Address 7� Phone Contractor's Name w 1 License No. ` � Phone On— 79' I L TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Q C Ve' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK __ SEWER LINES DISPOSAL FLD. rOV-1-.PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial�Y U Open,Bottom Manteca _ _Dia of Well Excavation L!!• _ - n ❑ Domestic/Private Gravel Pack Tracy 4 yDia. of�WellC�asi g"�" ❑ Public [-Other ❑ Delta Type of Casing y Irrigation Approx. Eastern 1 ❑Cathodic Protection ;ZC5 Depth ❑ `Specifications � Depth of Grout Seal too ❑Geophysical Type of Grout c •{Other Datr Surface Seal Installed b 7 y Q&14 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth QST Filler Material .(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDIT N J (No septic ank or seepage pit permitted if public sewer is available within 200 feet.)-. Installation will serve: Residence _ Commercial her Number of living units: Number of bedrooms Lo size Character of soil to a depth of 3 feet: Water table depth SEPTIC'TANK LJ `Type/Mfg C acity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capa 'ty Method of Disposal SEWAGE SYSTEM . Distance to'nearest: Well Foundation Property Line f. DESTRUCTION A LEACHING LINE ❑ No. & Length of lines Tot 1 length/size FILTER BED ❑ Distance to nearest: Wel Foundation Property Line k SEEPAGE PITS ❑ Depth ze Number 0 SUMPS U 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 workmant 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 applicanust ca fo required inspections. Complete draping on reverse side. Signed X Title: Date: �f R D P TM NLY Application Accepted byca-AA Area _06 ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by , Date Manteca 823-1104 Final Inspection by Date- ❑ Tracy - 835-6385 Applicant - Return all copies to: Envi onmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE MOUNT DUE AMOUNT REMITTED RECEIVED BY _ DATE PERMIT NO. INFO �}rU V EH 13-24 REV. 10/82 �` 10/82 500 # 14-26 r