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APPLICATION FC PERMIT SAN JOAQLi" LOCA! ti-_?.LTH '. ISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM 04TE ISSUED (Complete in Triplicate) Application is hereby made t th San Joaquin L al Health District fora permit to construct and/or install the work herein described. This application n c wit n Joaquin County Ordinance No, 549 for sewage or No. 1862 for well/pump and the Rules andaRegulatio o .0 alth D'-strict, Job Address 22 307- 0�-_Pwcme- Subdivision Name Owner's Name L 6)_u o e-S Address sopor k Phone Contractor's Name =1!►, CArtcif.e License No. 2Q 209) 13 Phone 923 -G5 By TYPE OF WELL/PUMA WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private ❑ GraveI Pack ❑ Tracy Dia. of Well Casing ❑ Public [j Other ❑ Delta Type of Casing �jirrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (tap 50'). Depth Filler Material (Below 5o', .---,> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION 7V(No septic tank or seepage pit permitted if public sewer is available within 200 feet.) o Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms �3 Lot size j Character of soil to a epth of 3 feet: P.4i 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 ❑ LEACHING LINE No. & Length of lines b = Total length/size � f FILTER BED ❑ Distance to nearest: "Well Foundation., .mm 1l _ Property Line SEEPAGE PITS ❑ Depth Size { Number SUMPS Ll 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-a-lb'd""Fegul-ations 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-i-n the performance of the work for which this permit is issued, I shall employ p frons subject to workman's compensation laws of California." The applicaALD& call f 11 requir d inspections. Complete drawing on reverse side. Signed X �"� Title: Date: F R DE TME U Application Accepted by Area _ � C} ❑ Stk 466-6781 Additional Comments: • ❑ Lodi 369-3621 Pit or Grout Inspection by Date } Manteca 823-7104 Final Inspection by "Date -_ _ - ❑ Tracy 835-6385 Applicant - Retur all cop s to: fnvironme aJ,,Health Permit,/Services "OD ,fl. Hazelton Ay,2., P. . 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