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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT 140. g3 --Zq Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED ]j]-{ (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for acPermit t6 construct and/or install the described. This application is made in compliance work herein with San Joaquin County Ordinance No. 549 for sewage or No. 1862 far well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Addresses Aryi�d� PAe' • �o ctei,±f Subdivision Name �(I✓ Owner's Name ¢„�,� p,,,yY1 Address '1� `� Contractor's Name Phone License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP -INSTALLATION -'❑--;-- SYSTEM-REPA-IR-- -❑' -OTHER--B _ DISTANCE TO NEAREST: SEPTIC TANK _ _ '� �"� SEWER LINES ,-., " 1 ' DISPOSAL-FLD. PROP. LINE .FOUNDATION _ l `. _�AGRICULTURE.WELL. - °` ` - ', OTHER WELL _PITS/SUMPS_- INTENDED USE TYPE OF WELL PROBLEM AREAw CONSTRUCTION SPECIFICATIONS Industrial o ❑ Open BottomManteca ❑ Dia. ,of Well Excavation LJ Domestic/Private Gravel PackTrac w Public ""' ❑ y. Dia. of Well Casing u ` [:j Other ❑ Delta w - Y ( Irrigation Type of_Casing Approx. � Eastern Cathodic Protection Depth Specifications.r i ❑ Geophysical Depth of Grout -Seal Other Type of Grout Surface Seal Installed by Repair Work Cone ❑ Type of Pump ' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) J Depth Filler Material (Below 501) [7 TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION . U (No septic hank or seepage pit permitted if public sewer is Installation will serve: ResidenceCommercial Other # ---,available within 200 feet.) Number of living units: Number,Of 13- *-Lot Y Character of soil to a depth of 3 feet': ??pro *~} 2 Water table depth SEPTIC TANK �j Type/Mfg ,( Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg " 'Method of Disposal SEWAGE SYSTEM Distance to nearest: '•_" oundation ' Property Line Well Foundation "-• DESTRUCTION ❑ LEACHING LINE -.No. & Length of lines./"� Total length/size 'FILTER k BED ❑ Distance to nearest: Well Foundation .� property Linc I -+ SEEPAGE PIF$ Depth ' b. `, Size k, Number a r SUMPS ❑ Distance to nearest: Well Foundation Property Line t 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 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 ll or al equired inspections. Complete drawing on reverse side. f� Signed X t Title: Date: . ! - R, ARTMENT USE ONLY Area / Application Accepted by ❑ Stk 466-6781 Additional Comments: ❑ Lodi. 369-3621F ' Pit or Grout Inspection by Date ❑ Manteca 823-7104 Y Final Inspection by Date ❑ Tracy 835-6385] � l�'t) Replicant - Return all copies to: Environmen 1 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CR 95201 r r f FEE INFO BASE AMOUNT JE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. s -9 93 33_ w- EH. 13-24 REV. 10/62.,._. 14-26 W._ ... 10/82 500