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I A,00 2-OS-OF0l0 E t APPLICATION FOR PERMIT [� SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES.1 YEAR FROM DATE ISSUED pQ (Complete in Triplicate), [J) 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 h San Joaquin Local Heal i Address to 6/ Job Owner's Name jWb Address FL- Phone Contractor's Nam ense No. _l��{ 3 Phon k 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 F INTENDED USE _ = C k TY?EI"OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy ,Dia. of Well Casing t ❑ Public ❑ Other ❑ Delta t� Type of Casing Irrigation lApprox. ❑Eastern Depth Specifications _ ❑ Cathodic Protection Depth of Grout Seal ❑Geophysical w Other + ', �. Type of Grout F-1 Surface Seal Installed by Repair Work Done ❑ Type of Pump h.P. State Work Done r Weil Destruction f_1 We]l Diameter Sealing Material (top 50') Depth Filler Material'(Below 50') s• TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (NG septic tank or seepage pit permitted if public sewer is i available within 200 feet.) Installation will serve: Residence �LCoolpmercial _ Other Number of living units po uz edf Be� �i dd-r++ooms 1__ Lot size 7� k f fff Character of soil to a depth of 3 feet: c-� � r� Water table depth SEPTIC TANKi�*Cj _[g Type/Mfg d Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal k � SEWAGE SYSTEM Distance to nearest: Well _ 1' ;Foundation Property Line' ` DESTRUCTION I ' LEACHING LINE No. & Length of line e _ d Total length/size - J PE ef) { �I� ' FILTER BED ❑ Distancr4e to nearest: Well (Foundation Property Line SEEPAGE PITS ❑ Depth 'I Size _ E Number L 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 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 �A� shall employ person subject to workman's compensation laws of California." The applicl re s e Complete,drawing on reverse side. Signed X Title: Date: ;FOR R T USE ONLY r Application Accepted by Area �(�j - ❑ Stk 466-6783 Additional Comments: #. ❑ Lodi 359-3621 Pit or Grout Inspection by Date �0( X Manteca 823-7104 Final Inspection by :; Date '],\Z-�3 L-1Tracy835-6385 Applicant -"Return all copies toy. Environmental lth Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT .IDUE AMOUNT REMITTED RECEIVED BY DATEPERMIT NO. INFO sal ' � Lf-s wo 8 3 EH 13-24 REV. 10/827 �C-� 739 10/82 500 I 14-26 t