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„ w -APPLICATIbN FOR PERMIT SAN_JOAQUIN LOCAL`HEALTH DISTRICTj`] 1601 ,E-. HAZELTON,AVE., STOCKTON,.CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ (Complete in Triplicate) r+ 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 Ordinanceo. 549 fo s e or No. 1862 for well/pump and the Rules and Regulations of theSanJoaquin Local Health District. j 6- i Job Address Subdivision Name 7-6 Owner's Name (,v r Address Phone Contractor's Name /GL[�i License No. n 7 5"`2' TC Phone {, TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT F_� DESTRUCTION -- - - _—PUMP"1NSTALLATION- --SYS DISTANCE�TO'NEARES75 SEPTIC`TANK SEWER'LINES' ''i" —DISPOSAL,FLD.- ""�" --PROP,r-LINE-- FOUNDATION AGRICULTURE WELL I OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom Manteca Dia. of Well Excavation 7 U Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing pp 17 Public Ej Other Delta Type of Casing irrigation Approx. ❑ Eastern # Specifications cathodic Protection Depth ; � Depth of Grout yeah •- ' � �+ Geophysical Type of Grout n + Other U Surface Seal Instalfed by _ Repair Work-:Done E] Type of Pump fH.P: State Work Done ” Well Destruction Well Diameter Sealing Material (top 50') - - --= fs. • . 1 - , s t y Depth t Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION01,.E,.REPAIR/ADDITION-,�"Ul;,,(hio septic,tank_or:seepage,pit permitted if public sewer is LLPavailable within 200 feet.) jt Installation will serve: Residence "-,Comm re cia;ll_ Other 1'- t Number of living units: ,.Number of-bedrooms'"' Lot size L. Character of soil to a-d`epth of 3 it : J3 Water table depth SEPTIC TANK �`� Type/Mfg . T i Capacity!, No. Compartments PKG. TREATMENT PLT Typ%Mfg r<, '" pac,ty 4i Method of Disposal 16 f SEWAGE SYSTEM ci Distance to nearest: Well Fpundatiori ': Property Line t DESTRUCTION ►" - LEACHING LINE No. & Length of lines '� ' j19�' Teal length size FILTER BED' F-1 Distance to nearest:, ,Well Foundation"-Z1 Property Line ; ti= i SEEPAGE PITS Depth -Size- _ Number.,: q SUMPS LJ Distance to:nearest: Well Folundatia _ _ Prope��ty Line ( DISPOSAL PONDS ❑ ( ` ' I hereby certify that I have prepared this application and that the work1wii1 be dbne in accordance with San Joaquin county ordinances; state laws, and rules and'regdlat.ions-of the San Joaquin Local Health District. { Home owner-or licensed agent's signature tify that in the performance of the work for which this gnature cerfif'ies thef.following: "I cer F permit is issued, I shall not employ any person in-Lsuch md;nner 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 compeiisat`iGh`lars of.'Galifornia." The applicant must ca f 11 re i d inspections. Complete drawing on reverse side, Signed X Title: } f Date: DEP RTMENT USE ONLY Stk 466-6781 OR Application Accepted by Area �� Additional Comments: Lodi 364-3621 Pit or Grout Inspection by i Rate;; 1 1 !� ❑ Manteca 823-7104 Final Inspection by T Date ` Q Tracy 835-6385 { Applicant - Return all copies to: Environmental •th-Permit/Services 1601 E. Hazelton Ave.,, P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED ' RECEIVED BY DATE PERMIT N0. 'n` INFO —17:7 '. s 10/82 Sao EH 13-24 < REV. 10/82 14-26 ,