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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED I! " (Complete Trigl;,�ate)�, � Application is herebyff made to th�5an Joaquin cal Health District fora 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. 18 for well/pump"" a� and the Rules and Regulations.of the San Joaqui Local Health Dig�s-t-rijt, /Jr w e. op Job Address �Qi4isiSr� fiF Rd Owner's Name 'J� ` rte" Phone Contractor's NameLIMLicense 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 FLO. PROP. LINE Z FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k Industrial ❑ Open Bottom Manteca y ❑ Dia. of Well Excavatio_n _ ❑ Domestic/Private Gravel PackTrac - ❑ Y Dia. of Well Casing ❑ Public ❑ Other [] Delta LjIrrigation Type of Casing Approx. Eastern r ❑Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal ❑Other Type of Grout 4 Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Workt Done Well Destruction ❑ Well Diameter Sealing Material (top 50') F Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage.pit.permitted if public sewer is Installation will serve: Residence I Commercial Other available 4ifthin 200 feet.) I 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 city L-9 J1 No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM + Distance to nearest: Well Foundation Proper_ty.Line.o�.w..} DESTRUCTION C] LEACHING LINE No. & Length of lines � i Total length/size FILTER BED4. Distance to nearest: Well Foundation � Property Line'""s SEEPAGE PITS qf Depth �ASize Number SUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 is issued, I shall employ persons subject to workman's compensation laws of California." f The applicant must c 1 for all ui ed inspection Com lete.drawin on reverse.side•. P P 9 ,w.r,,.r�.tar .�..rr......Y Signed X Title: Date: /df Application Accepted by D E ONLY Area Q Stk 466-6781 Additional Comments: p/y__% d 369-3621 Pit or Grout Inspection by Date �/� Manteca 823-7104 JV ` Final inspection by� pateTracy 835-5385 Applicant - Return all copies to: En ironment Health Permit/Services 1601 E. Hazelto b#�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 F