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ki •:was 1 af' APPLICATION FOR PERMIT ( SAN JCAQUiN LOCAL HEALTH DISTRICT .=,`.w� I 1601 E. HAZELTON AVE., STOCKTON, CA �p PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED ( ,rj (Complete in Triplicate) Application is hereby made to s me described. This application is ma' an Joaquin Local Health District for a permit to construct and/or install the work herein k de in compliance with San Joaquin County Ordinance No. 549 for sewage or No, and the Rules and Regulations of the San Joaquin Local Health District, 1862.for well/pump Job Address - Subdivision Name Owner's Name ape A59E ff A,4 9' J" Address � Contractor's Namehone (RS w ,�/_,�F. 4i/ _ License No. Phone TYPE OF WELL/PUMP WORK: NEWiWELLWELL REPLACEMENT ! ❑ ❑ DESTRUCTION ❑ , PUMP'INSTALLATION ❑ 'SYSTEM REPAIR= ❑ - OTHER DISTANCE TO NEAREST: SEPTIC TANK } SEWER LINES _ DI5POSAL FLD_ PRDP, LINE I FOUNDATION ! AGRICULTURE WELL OTHER WELL _ PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM.AREA CONSTRUCTION SPECIFICATIONS Industrial a. Open Bottom Manteca a ❑ 'Dia.`of We1lwExcavation ❑ Domestic/Private ❑ Gravel Pack Trac '" ❑ Public i ❑ y Dia,4of Well Casing ❑Other ❑ Delta �w Lj Irrigation 3 rType of Casing j -Approx..,,-.Q Eastern .... �.. [Cathodic Protection' Depth Specifications - U Geophysical .. , Depth of Grout Seal U Other Type of Grout Surface Seal Installed by { . Repair Work Done �] Type sof Pump H p •`•--._-- State Work,Done t Well Destruction ❑ Well Diameter Sealing Material (top 50') gepth Filler Material (Below 501) ,L TYPE OF SEPTIC WORK: .NEW.INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage�pit permitted if public sewer O is Installation willserve: Residence s✓ Commercial _ Other `' available within 200 feet.) `, Number of living units: !. Number of bedrooms Z. — Lat size Q !j� - # Character of soil to adepth of 3feet: a j z L,J/ ,,Water table depth SEPTIC TANK � ll Capacity p y No. Compartments PKG. TREATMENT PLT. � y g i Capacity SEWAGE SYSTEM p y Method of Disposal DESTRUCTION Distance to nearest: Well .t -, Foundation Property Line LEACHING LINE Total length/size, FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 _ SEEPAGE PITS ❑ Depth �� Siie Air Number SUMPS k LiDistance to nearest: Well Foundation -- Property Line DISPOSAL PONDS r F toy 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 call for 1 required inspect' s. Complete draG,ing on reverse side. " Signed X i Title: Date: F EPA NT USE ONLY Application Accepted by � Area Stk 466-6781 Additional Comments: r ❑ Lodi 369-3621 Pit or Grout Inspection by Date -' j= Manteca 823-7104 Final Inspection by Dale /S d3 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave•, P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO EH 13-24 REV. 10/82 14-26 10/82 500