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r r.v APPLICATION FOR PERMIT e` SAN JOAQUIN LOCAL HEALTH DISTRICT; 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) E Application is hereby made to the San Joaquin 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 d pIQ ations of the San Joaquin Local Health District / �C Job Address �( ivision N&me ,r Owner's Namess 37 -. Phone tJ - = Contractor's Name License No. -- ?.�,/ tio[ie -� M TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION O r - PUMP INSTALLATION [];; SYSTEM REPAIR k - OTHER ,DISTANCE TO NEAREST: SEPTIC TANK INES DISPOSAL FLD. i 'PROP. LINE A 1� ti FOUNDATION AGRICULTURE LL OTHER WELL ; ` PITS/SUMPS INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ale Industrial t E]Open Bottom E]Manteca Dia, of Well Excavation f2w µ Domestic/P,rivate Gravel Pack 'Tracy Dia, of Well Casing 4 i Public F-1 Other Delta Type of Casing Lj Irrigation Approx. 0 Eastern — ` /.• .. Specifications Cathodic Protection fJ Depth Depth of Grout�eal Geophysical Type of Grout Ql /V w •O ❑Other Surface Seal Installed by U Repair Work Done ❑ Type.'of Pump H.P. State Work Done Well Destruction,�Well Diameter " Sealing,Material (top 501) Depth Filler Material (Below 50`.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer;s`" ue" ""} ; x available within 200 feet.) Installation will' serve: Residence _ Commercial, .,;Other, Nom. h-111 - Number of living units: s Number of bedrooms Lot size Character of'soil to a depth of 3 feet: -Water table depth SEPTIC TANK Cj Type/Mfg Capacity No. .Compartments, PKG, TREATMENT PLT.: Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation 5 . .Property Line _ T i LEACHING LINE EJ No. & Length of lines Total length/size 4 FILTER BED Distance to nearest: Well k Foundation 4 . •� Property Line SEEPAGE PITS Cj Depth Size A Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS it 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 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 in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." E The applicagmus Pca 1 for required inspections, Complete dray g on rerse sid c� Signed X Title: Date: FPR ENT USE ONLY ^Y 3 Application Accepted byCt.A rea D - Stk 466-6781 AdditioqAl Comments: - [� Lodi 369=362.1 - Pit or rout I spection by ate V.—1 S El Manteca 823-7104 Final Inspection by AX Date Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEPERMIT NO. INFO 143 1 ,8-1q ss yt- 97S EH 13-24 REV. 10/82 10/82 500 I 14-26