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4 APPLICATION FOR PERMIT SAN JOAQbiN LOCAL HEALTH DISTRICT L� 4 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. k Tele`phdr;-� (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hefeTh 7� described. This application is made in compliance with San Joaquin County Ordinarce No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulation f the San Joa ui Local Health District. Job Address t(lldlm Subdivision Name Owner's Name Address Phone Contractor's Name.. a Q );� )1License No. 7 _ Phone TYPE OF WELL/RUMP WORK: NE4I�WELL r. r WELL REPLACEMENT DESTRUCTION �� 11qPUMP INSTALLATION SYSTEM REPAIR OTHER U / DISTANCE TO NEAREST: SEPTIC TANK X SEWER LINES _DISPOSAL FLD. le 6 t-PROP. LINE e FOUNDATION 2 Q �- AGRICULTURE WELL OTHER WELL r�.._ - I— PITS/SUMPS e&a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J IndustrialU Open Bottom Manteca} � 1 Oia,.\of Well Excavation Domestiy?ms. --c/Private - Gravel Pack Tracy Diaof Well .-Casing - K ---- _ ❑ d Public J Other Del to ��,� / _)ype of Casing LI Irrigation Deprox. Eastern �� Specifications_..." ❑ Cathodic Protection Depth !t k = g( Dept o44f;Groout Seal Geophysical r 7y p. I Grout �i U Other a, i Surface Se—al-In`stalled by Repair Work Done Type of Pump i H.P. .-----State"Wo-rk-9one_Y-1 } �� Well Destruction U Well Diameter; Jam. Sealing Material,(top 50') f Depth Filler Material (Below 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION JF-1 REPAIR/ADDITION (No septic talk or seepage pit permitted if public sewer is Y � 2: avaiilable within 200 fee,t1�-) m Installation will serve: Residence _ Com��cia1 Other ' y � r4 Number of living units: Number of bedrooms f Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfgt fj Capacity No. Compartments PKG, TREATMENT PLT. ❑ Type/Mfg' j Ca'acity Method of Disposal SEWAGE SYSTEM Distance,to nearest- Well Wunda i.on., Property Line 1 DESTRUCTION I g � " I r LEACHING LINE U No. & Length of lines Total length/size r ---i FILTER BED ❑ Distance to nearest: Well �_ Foundation Proper-ty..L- ne—. i r a SEEPAGE PITS ❑ Depth Size Number 1, SUMPS U Distance to nearest: WellFoundation Property Line I t d ti ey DISPOSAL PONDS ED F y ' 3 1S t I hereby certify that I have prepared this application andlthatthe work will Itf2"Itotre-in accordance with San boaquin couhlty ordinances, state laws, and rules and regulations of the %n Joaquin Local Health District. i i i ) Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whichtthis permit is issued, I shall not employ any person in such mahhner as to become subject to worknanq,compensation laws(of Cal,Tfgrnia." Contractor's hiring or sub-contracting signature Certifies) the following: "I certify that in the performance of the work f6r which this permit is issued, I shall employ persons subject to Irkman's compensation Ia0'of,CaTifornia." The appli ant must all required inspections: -Complete drawi n�re er side// IAN Signed X Title: /— Date: /_ / R EPARTMENT U ONLY X22— "�-- Application Accept by !/V Area l 7 Stk 466-6781 Additional Commen s: Lodi 369-3621 Pit or Grout Inspection b Date 2 Manteca 823-7104 1 Final Inspection by Date a�_ L Tracy 835-6385 Applicant - Return all copies to: '' Environment(I)Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Std, CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO.' INFO � �A9 EH 13-24 REV. 10/82 10y82 500 14-26