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Y - APPL1CA710N FOR PERMIT SAN JOAQUIN LOCAL }HEALTH DISTRICT 1601 F, HAZELTON AVE., STOCKTON, CA PERMIT NO. �S A-7 Telephone (209) 466-6751 DATE ISSUED S-� PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED 4 (Complete in Triplicate) e San Joaquin Local -Health District for a permit to construct and/or install the work herein Application is hereby made to th described. This application is a San n compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address P. • Subdivision Name Address Phone Owner's Name - �s 'f' r — ' ! License No. Phone Contractor's Name TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION i 4, OTHER PUMP INSTALLATION � SYSTEM REPAIR � U DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1J Industrial U Open Bottom Manteca Dia. of Well Excavation LJ Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing Public F-10ther� [ Delta Type of Casing L iirrigation Approx. [] Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout w Other 'surface Seal Installed by Repair Work Done [:] {top 5 ) Type .of Pump n, H,P, 50Work Done i Sealing Well Destruction U Well Diameterl.- �- 9 Material Depth Filler Material (Below 50') sewe TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit availableewithinubl200cfeet.) is n Installation will serve: Residence Commercial Other l Number of living units: INumber of bedrooms Lot size Water table depth Character of soil to a depth of,) feet: Capacity No. Compartments r SEPTIC TANK �j 7y pe/Mf9 Method of Disposal PKG. TREATMENT PLT. E] Type/Mfgi Capacity Property Line Prop SEWAGE SYSTEM �y Distance' to nearest: Well Foundation , DESTRUCTION 1fi► 1 No. & Length of lines Total length/size LEACHING LINE 9 } Foundation Property Line FILTER BED Distance:to nearest: Well � SEEPAGE PITS ❑ Depth Size Number Distance to nearest: Well Foundation Property Line SUMPS `L_I y 1 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 rulesland regulations of the San Joaquin Local Health District. owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this Home own fff permit 1e issued, T shall not employ any person'in such manner as to become subject to workman compensation laws of California." certifies the following: "I certify that in the performance of the work for which Contractor's hiring or sub-contracting signature t bject to workman's compensation laws of California." this permit is issued, I shall employ persons su The applicant must call for all required inspections. Complete drawing on reverse side. Date: "r Signed X {> �� Title: 0 DEPARTMENT USE ONLY Area � Stk 466-6181 Application Accepted by Lodi 369-3621 Additional Comments: Manteca 823-7104 ' Date Z-� Pit or Grout Inspection by `� Final Inspection by Date Tracy 835-6385 lApplicant - Return all copies to: Environmental Health Permit/5ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., LA 95201 f DATE PERMIT NO. ! FEE BASE AMOUNT .DUE AMOUNT REMITTED RECEIVED BY / ` INFO # / kwgs i 4-7 a 10/82 500 Eh 13-24 REV. 10/82 i Q7 14-26 a