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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA Tele hone (209} 466-6781 PERMIT N0. EI 3 C\ TYPE OF WELL/PUMP WORK: NEW WELL DISTANCE TO NEAREST PUMP INSTALLATION SEPTIC TANK t� FOUNDATION WELL REPLACEMENT ❑ SYSTEM REPAIR SEWER LINES AGRICULTURE WELL ❑ DESTRUCTION ❑ OTHER J DISPOSAL FLD. OTHER WELL PROP. LINE PITS/SUMPS INTENDED USE TYPE OF]WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ Industrial U Open Bottom F -I Manteca p DATE ISSUED Pack F -11 -racy Dia. of Well Casing PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Delta a Type of Casing V Irrigation Approx. ❑ Eastern (Complete in Triplicate) , atoc Protection Depth ❑ChdiPti Application is hereby made to the Sari Joaqui6 Local Health District for a permit to construct and/or install the work herein described. This application is madejin compliance witt San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of t e,San Joa u`in Local Health District., Depth Filler Material (Below 50') Job Address j_Lk ��i �: Subdivision Name tk ' Owner's NameAddress Installation will serve: Residence _ Commercial ti Phone�°L�4 -�850 Contractor's Name T�ir.tia� Character of -soil to a depth of 3�feet: t�€j�� License No. Phone . TYPE OF WELL/PUMP WORK: NEW WELL DISTANCE TO NEAREST PUMP INSTALLATION SEPTIC TANK t� FOUNDATION WELL REPLACEMENT ❑ SYSTEM REPAIR SEWER LINES AGRICULTURE WELL ❑ DESTRUCTION ❑ OTHER J DISPOSAL FLD. OTHER WELL PROP. LINE PITS/SUMPS INTENDED USE TYPE OF]WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ Industrial U Open Bottom F -I Manteca Dia, of Well Excavation U Domestic/Private ❑ Gravel Pack F -11 -racy Dia. of Well Casing ❑ Public ❑ Other,. Delta a Type of Casing V Irrigation Approx. ❑ Eastern Specifications atoc Protection Depth ❑ChdiPti Depth of Grout Seal t ❑ Geophysical TypeofGrout Lf Other Surface Seal Installed by" Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter : Sealing Material (top 501) _ Depth Filler Material (Below 50') a TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION(No septic tank or seepage pit permitted if public sewer is X tk ' 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 Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg i Capacity Method of Oisposal� SEWAGE SYSTEM Distance to nearest:. Well .Foundation Property. Line DESTRUCTION ❑ F LEACHINGjLINE � No. & Length of --Tines � ��-. Total len th/size �`�_ j� 9 FILTER BED ❑ Distanceito nearest: Well Property Line �^ Foundation 1� p s SEEPAGE PITS 'XDepth _2 Size SC Number ! w. SUMPSit ❑ Distance�fo nearest: Well - Foundation 1 © t Property Line 5 DISPOSAL PONDS CI 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. the for which this Home owner or licensed agent's signature certifies the following: in "I certify that in the performance of work to become subject to workmanis compensation laws of California. permit iss , I shall not employ any person such Contractor's ing or sub -contracting signature certifies manner as the following: I certify that in the performance of the work for which this permi s issued, 1 shall employ persons s ject to workman's compensation laws of California." The appli _a "-for 1 requ' a insp ions. Complete awing on everse side. Signed �, e: Date: OR DEPARTMENT '.USE ONLY ll Area 110�rStk 466-6781 Application Accepted by --✓+�11L Additional Comments: [] Lodi 369-3621 Grout Inspection by Date Z _ - �� ❑ Manteca B23-7104 Pit or Final Inspection by Date 2— '73 ❑ Tracy 835-6385 Applicant -- Return all c to. (Environmental Health Permit/ ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE � BASE AMOUNT DUE INFO117 EH 13-24 REV. 10/82 14-26 AMOUNT REMITTED RECEIVED BY ! DATE ai (A PERMIT NO. B3- T1 10/82 500