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APPLICATION FCri PERMIT SAN .lOAQlii'! LOCAL HEALTH D'eSTRICT 1601 E. HAIELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 '' �^ DATE ISSUED F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the;San Jadquin Local Health District for a 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. 1862 for well/pump and the Rules and Re ulation of the Jo i oval Health District. Job Address Subdivision Name Owner's Name Address _ _ c s Phone . rContractor's Name _d_,(, � ollC License No., e2 �� _ _ Phone TYPE OF WELL/PUMP WORK; NEb1 WELL F— WELL REPLACEMENT DESTRUCTION ❑ t PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK F SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr,� IJ Industrial U OperlBottom F-1 Manteca Dia. of Well Excavation rW U Domestic/Private ❑ Gravel Pack { Tracy Dia. of Well Casing lT' L Public F-1 ether Delta T^' Irri ation Type of Casing u► g •.-- _-. .._ �,•Approx.„ _. Q Eastern �.Specifications Cathodic Protection Depth -'" ,Y ,•s Depth`of,Grout Seal Geophysical Lf Other ",Type'of Grout 'tv Surface Seal Installed by Repair Work Done -Type of Pump H.P. State Work Done , -1 g Well Destruction ❑ we11;,Di�meter Sealan Ma�tefial (top`50'')" r� 3 Depths'{ ( a° —�F it ler(Material (Below 50' � ;�T_Y.PEyp�SERJ,LCYWORK �NEWrI-NSTALLAT.ION- N-REPAI-R/ADDITION -j (No's`ept� t3n#c oT seEpdge'pit permitted-if`Quti°1ic-'sewer-i•5 t G available within 200 feet.) Installation will serve: Residence-, % Commerc alt Other,, Number�of-A i v i n 9-u n i t n, Number of'bedr_O6hs� Lot. size--? Character Df soil to'a deptk of 3 feet; 12,a `- Water table depth. i' SEPTIC TANK Type/Mfg gid' Capacity No. Compartments •,5'ti;•�..q PKG. TREATMENTrPLT:,. f Type/Mfg 'I Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION r LEACHING LINE No. & Length of lines Total length/size `3 p, p i FILTER BED ~~ Distance to nearest':--Well•.---- Foundation _- --Property-Lone ( SEEPAGE PITS Depth F Size Number SUMPS I�I �TDistance tto nearesi7 ""Founddt'ion*�^^T Property Line DISPOSAL PONDS LI I hereby certify that I have prepared this application and that the work will be done in accordasc�e 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, 1 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 is compensation laws of California." The applicant must cal,4 for all re iced inspections. Complete drawing on reverse side, fy ? Signed X Title: i Date; �- R DEA TMENT USE ONLY Application Accepted by ': `-�� c r Area i ❑> Stk 466-6761 Additional Comments: FLodi 369-3621 ' Date ! � Manteca 823-7104 Pit or Grout Inspection by � (] f Final Inspection by Date ;W-7 y / / O� �J LI' Tracy 835-6385 ] Applicant - Return all copies to; Environ al Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 ' FEE BASE AMOUNT DUE MOUNT REMITTED tREGEIVED BY -.w ; DATE PERMIT NO. f INFO w !f 7 G. ��1;7610/82 500 .. . ..EH:.}3_24 REV. 10/82,. _., . .,- f / ,. —rV � 14-26