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noAPPLICATION FOR.PERMIT LSAN JOAQUIN LOCAL HEALTH DISTRICT SEP 2 61883 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (20q) 466-6781 SAKI JOAQUIN LOCAL PERMIT EXPIRES 1 YEAR FROM DATE 1S SUED DATE ISSUED N_kV3 HEAL!H DISTR!CT (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 7 Subdivision Name Owner's Name fes_, .dl.le_ Address 0vU Phone Contractor's Name License No.: Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ndustrial '"�� " .-T- �f Open Bottom Manteca b'ia: Domestic/Private Gravel Pack Tracy Dia. of Well Casing F Public Other ❑ Delta Type of Casing Ll Irrigation Approx. L) Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal 1-1 Geophysical Other � Type of Grout Surface Seal Installed by Repair Work Done E] Type of Pump &,�, H.P. State Work Done &A,. Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 5O') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION D (No septic tank or seepage pit permitted if public sewer is ,J 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 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 Q LEACHING LINE U No. & Length of lines _ Total length/size FILTER BEO Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS gistance to nearest: Wel l 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's 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X 0-a.., yyl L aAdt,,,. it Title: Date: DEPARTMENT USE ONLY Application Accepted by _ Area Stk 466-6781 Additional Comments: F1 Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by '^ s z ��., n � Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT 14 T NO. INFO 1 g 3v S3 ?3-1a,00d EH 13-24 REV. 10/82 10/82 500 14-26 _ i