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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM GATE ISSUED (Complete in Triplicate) 655-- IS o - As 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 and R g 1 tigns f e Ua oaquin ocal ea th District, Job Address / Subdivision Name Owner's Name l, -' Address Phone Contractor's Name /rY /J,f License No. Phone —C TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION � SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /!/ex4/ SEWER LINES %e O f` DISPOSAL FLO. PROP. LINE `J� a FOUNDATION 7// f AGRICULTURE WELL OTHER WELL P ! O -4-PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation ski y/>!C Ct .y❑ Domestic/Private Lldravel Pack ❑ Tracy Dia, of Well Casing /Z/mow e,4 [AKuhIic Cj Other ❑ Delta Type Irrigation pec of Casing / ��,%�� •- U 9 Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth l Depth of Grout Seal `a'� _ ❑Geophysical ,A ��',,,, _ )�{✓.Z/� Type of Grout i7 ❑Other ,/�`Z{�cv(' / .�r� 2/�S �rrface Seal Installed by l� �v A,5Z_gy3 Repair Work Done✓ Type of Pump H.P.�14 � '+�"KYSte Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK F j Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal JEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line S PAGE PITS F-1DepthSize Number ,i ISu PS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 workmank compensation laws of California." f 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 or ll required inspections. Complete drawing on/reverse side. day ISAgned X Y- r /lam—7ytle: 13 � %�1�7 "c' '- Date: 1F R DEP RTMENT USE ONLY / -T- Application Accept' d by - ✓L- Area ❑ Stk 466-6781 Additio em`nents: S` %yJ GG/ l /zl �iGtLK -Lodi 369-3621 Pit Grout I pection by >z - Date 3• - C ❑ Manteca 823-7104 Final pection by _ u - Date, 0 /y_y/ [I Tracy 835-6385 Applicant - Return all copies to: r mental Health Per 1601 E, Ha zelton'Tve., 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 10/82 500 14-26