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APPLICATION FOR PERMIT 10/7,Z.' LFXio•�+w �.+t CQyy1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NOgf t Z.q W eAJ Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rfamplete in Triplicate) 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 a d�ee tions of xhP can qu'n Local ealth District, Job Address .., Subdivision Name Owner's Name 4whk co-r Address Phone 3�— , ,�/0 Contractor's Name ,Y` ,S License No. 7 4> Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 161d !I- DISPOSAL FLD. PROP. LINE FOUNDATION �—' AGRICULTURE WELL OTHER WELL !e4 - PITS/SUMPS ��C7 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS // I� Industrial Open Bottom F-1MantecaDia. of Well Excavation /Z /Nd N Domestic/Private Gravel Pack Tracy Dia. of Well Casing !/fC-11 1-1 Public ❑Other � U :--= .: - Delta J Irrigation pa Approx. Eastern Type of Casing Specifications '"-< Cathodic ProtectionDepth - _ ❑Geophysical Depth of Grout ❑Other Type of Grout Surface Seal Installed by `dj' � , Repair Work Done Q Type of Rump %Y4J 3 H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms Lot size a Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ } LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS IJ Distance to nearest: Well Foundation Property Line 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 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 t 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." The applicant must call for all required inspections. Complete dr . g on reverse side. Signed X Title: NAPTA/4e__T0F{ Date: .44115 4fS OR DEPARTMENT USE ONLY/ Application Accepted by Area Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by r Date C Manteca 823-7104 Final Inspection by Date ( Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1961 : Hazelton,Ave., P.O. Box 2009, Stk„ CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ~PERMIT N0. INFO Aa, QUID ZF{�FS 8sr►z� �, "`--� EH 13-24 R&V. 10/82 14-26