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>. APPLICATION FOR PERMIT SAN JOAQUiN L(3',AL HEALTH DISTRICT AZ7 1601, E. HAZELTONi VE#STOCKTON, CA PERMIT NO. Q U©� .1, Telephone X209) 466-6781 y DATE ISSUED c9' !� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ir (Complete 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 rdinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Reka ions of th� San ,lodqui 0 1 H Itfg s ict. Job Address 7777JJ�� SJubdivis,o a ' Owner's Name { Adress Phone Contractor's Name cense No. Phone tq .,c ' TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION O� ' PUMP INSTALLATION SYSTEM REPAIR OTHER U 6 DISTANCE TO NEAREST: SEPTIC�TANK SEWER LINES OISPOSAL FLO. PROP. LINE f �) FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v F INTENDED USE TYRE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 1 Industrial U Open Bottom E]Manteca Dia. of Well Excavation U Domestic/Private © Gravel Pack ❑ Tracy Dia. of Well Casing i El L Public Other Delta Type of Casing F Irrigation IM Approx. L] Eastern Specifications l ❑ Cathodic Protection I Depth G_ Depth of Grout seal___ I--]Geophysical Y Type of Grout U Other Surface Seal Installed by r� • i Repair Work Done 1-! Type of Pump H.P. State Work Done k Well Destruction U I Well Diiiameter Sealing Material (top 50') � Q Depth �l Filler Material (Below 50') ° TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION (No septic tank or seepage pit permitted if public;-sewer -is-. available within 200 feet.) tJ" Installation will serve: Residence Xk Commercial Other Number of living units: . ' Number of bedrooms Lot size C Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments — d PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal# SEWAGE SYSTEM Distance to.nea.res.t: Well Ej Foundation 0 Property Line 0 j DESTRUCTION ❑ IM 1 LEACHING LINE U No. & Length of lines S Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS F] Depth i Size Number ' h SUMPS Distance to nearest: Well, Foundation Property Line f DISPOSAL PONDS ❑ �� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county I 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 I 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 subs,contracting signature certifies the following: "I certify that in the performance of the work for which i this permit is issued, I shallBepypersonssubject to workman's compensation laws of California." The applica 1 or aled inspections Complete dr wing on reverse side. Signed x Title: Date: FOR PA TMEF USE ONL QStk 466-6781 Application Accepted by tic.- Area Additional Comments f: Lodi 369-362 Pit or Grout Inspection by Date Manteca 823-1104 / Date / _-_ ❑ Tracy 835-6385 Stk., Final Inspection byM - L r Applicant - Return all copies to: Environmental Health Permit/Services 16 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO `! 4 LAS 13 EH 13-24 REV. 10/82 10/32 500 14-26 Cv� I