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! 0 �I APPLICATION FOR PERMIT SAN JOA UiFI LOCAL HEALTH uiSiR1CT Q /a: 00 A,W, \ 1 1601 E. HAZELTON AVE,, STOCKTON, CA Telephone (204) 466-6781 PERMIT NO. i+ DATE ISSUED 1 ! IN LOCA4. PERMIT EXPIRES.1 YEAR FROM DATE ISSUED A SAN XLH ®ISTFt1C�C, (Complete in Triplicate) Application is hereby made to the is iSan Joaquin Local Health District for a permit to construct and/or install the work herein in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump described. This application made and the Rules and77 Regulations of the San Joaquin Local Health District, Job Address_ -�/ E oA-K oaP Sr iµi�iaA-Flame % l 'IPJIiI/Jt!F7?t7 _ _ Phone Owner's Name L /L/ Address Name t4U�4t -LVJ ( NQcense No. Phone 7��9 3377 Contractor's 16.1001 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U ' PUMP INSTALLATION SYSTEM REPAIR OTHER U 'a~ LINE a < DISTANCE TO NEAREST: SEPTIC TANK �� ® � _ SEWER LIN E5 c7� S^U _DISPOSAL FLD. -� PROP. hi E FOUNDATION AGRICULTURE WELL,— OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rf N Industrial Open Bottom � Manteca Dia. of Well Excavation %� EX�n,V 6----- -N-Domestic- Private �-Gravel-Pack Tracy W = Dia. of Well Casing Public F-1 0ther Delta Type of Casing S %ESL Irrigation Q Approx. Eastern Specifications 6,4, Cathodic Protection Depth Depth of Grout Seal Q � Geophysical Type of Grout _ �� (5 Aa4e % Other w, Surface Seal Installed by 771e'ZU-IA116 Repair Work Done Type of PumpSud H.P. State Work Done ,til Via Well Destruction U Well Diameter Sealing Material (top 50') W6_Z4w..- r Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INST TION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 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 i +� LEACHING LINE U No. &'Length of lines _ Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [] Depthi Size Number 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 r s to become subject to workman § compensation alaws of California." permit is issued, I shall not employ any person in such manne 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 work1�an's compensation laws of California." The applicant ust.call fo all�req r d'tispections. Complete drawing onreverseside. %Q Signed X Title:` Date: OR PARTMENT NLY I d dl. Application Accepted by i Area Stk 466-6781 Lodi 369-3621 Additional Comments: Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by I ' ate Tracy 835-6385 Applicant - Return all copies to:. Environmental Health Permit/Services 1601 E. Hazeltor Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMO�U+NpT OUE AMOUNT REMITTED RECEIVED BY DATE ::;PER�NO.INFOC .�g 10/82 500 EH 13-24 REV. 10/82 14-26 moi: Fy �0 1V