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APPLICATIOTY" FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT N0, r l 3 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 and the Rules and Regulations of• the San Joaquin Local Health District. or No. 1862 for well/pump Job Address" .?5-8 ')� r/7e. Subdivision Name k Owner's Name W. C. SrFj�7�,')osl Address .7S✓PSS- . �sJ/j�y� �Scy,GPhone Contractor's Name /G/ V7,6VIV -f -5'0'A--1 License No. Phone 5-A3- TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 1 I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4-1l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS17 Industrial ❑ Open Bottom Manteca V' I ❑ Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack []Tracy Dia. of Well Casing Public ❑Other ❑ Delta LjIrrigation Type of Casing Approx. ❑ Eastern ❑ Cathodic Protection Depth Specifications 0 Geophysical Depth of Grout Seal U Other Type of Grout Surface Seal Installed by Repair Work Done [ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') 4 a TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is d Installation will serve: Residence X Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms -, Lot size AA Y�s Character of soil to a depth of 3 feet: SAVdl Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE U No. & Length of lines /4o Total length/size FILTER BED Distance to nearest. Well /oa f- Foundation /o` Property Line !t1` SEEPAGE PITS Cj Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 7Per.itis ertify that I have prepared this application and that the work will be done in accordance with San Joaquin county , state lsand ules and regulations of the San Joaquin Local Health District.r linsed agent's signaturecertfiesthe follwing: "I certify that in the performancof the work for which thisissuedIhanot emplynyperson in such manner as to became subject to workan compensation laws of California."hiringrbontracting signature certifies the following: "I certify that in the performance of the work for which issued, I shall employ persons subject to workman's compensation laws of California." The applicant'muuu t call for 11 required inspections. Complete drawing on reverse side. Signed Title: Date: 6 3y Fy D MENT USE ONLY Application Accepted by _ r_Area Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Applicant - Return ail copies to: Environ n aT Health PermDate (racy 835-6385 Permit/Services 1601 E. Hazelton Ave., P. Box 2009, Stk.,-CA" 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO DATE PERMIT NO. 41S to [a 3 _ x{-73 EH 13-24 REV. 10/82 14-26 10/82 500