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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 f A- DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Mr {Complete in Triplicate) �� Z Application is hereby made to the San Joaquir 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 Regulations of the San Joaquin Local Health Di tric //�� Job Address _ "ubP71 Ad a /7� Owner's Name Address one Contractor's Name ! o. Phone TYPE OF WELL/PUMP WORK: NEW WELL + WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER J DISTANCE TO NEAREST: SEPTIC TANK �ifil- SEWER LINES - DISPOSAL FLO. &1k PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !J Industrial U Open Bottom X Manteca Dia.: of Well Excavation } t R ,O'llomestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing ublic Other Delta P ❑�P3 ❑ ❑ Type of Casing _ ❑jalrrigation 1 n Approx. ❑ Eastern Specifications T f BILE Flo s Depth ❑Cathbdic Protection Depth of Grout Seal 30 � _. 'I'. a l ❑ Geophysical s k Type of Grout ❑Other Surface Seal Installed by i Repair Work Done G Type of Pump H.P. State Work Done Well Derfitsuction Well Diameter Sealing Material p (top 50T) ~' dr/1 u e th ,.Filler Material (Below 50') lvvvlll fTPL P,SEPII W STALLRTLON F-1 REPAIR/ADDITION J (No septic tank:or seepage pit permitted if public sewer is I available within 200 feet.) Installation will serve: Residence Commercial Other f , raumber of I ivirig units: Number of bedrooms � _1_...,.L.o� laze Character of sail to a depth of 3 feet: X Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments .� PKG. TREATMENT PLT. L] Type/Mfg -~3 CapacityMethod of. Disposal SEWAGE SYSTEM Distance to nearest: Well "Foundation 3 ' � Property line. trDESTRUCTION ❑ `, LEACHING LINE ❑ No. & Length of lines it - Total length/sie FILTER BED ❑ Distance to nearest: WellFoundation ..i Property Line SEEPAGE:PITS ❑ Depth Size SUMPS' # ❑� Distance to nearest: Well Foundation, _ � {PropertyLime~--i 4 i DISPOSAL PONDS I hereby certify that I have prepared thisiapplication and that the work will be done in accordance with San Joaquin_Tcpuniy:=< _ 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 workmant compensation laws of California." I Cohtractor's hiring or sub-contracting siighature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ perspns subject to workman's compensation laws of California." The appFlican s ca for required ins'Octions. Complete drawing on reverse side, a'r Signed X Title: Nte ' 0 D ARTMENT US ONLY �� Application Accepted by Area _L -__- "+ ❑ Stk 466-6781 t ❑ Lodi 369-3£21 Additional Comments: .- . Pit or Grout Inspection b Date 'h p� Manteca 8234104 P y . i f Final Inspection by Date -❑ Tracy `835-5385 Ap�plica€nt - Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. -Box 2004•, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DAT�aS`l PERMIT`ND. `+ INFO �`�`a— EH 13-24 REV. 10/82 10/82 500 14-26 3