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APPLICATION FOR PERMIT1 ,7 10 f + SAN JOAQUIN LOCAL HEALTH DISTRICT �i - 160 - 1 E. HAZELTON AVE., STOCKTON CA = Telephone (209) 466-6781 RERPIIT N0. DATE ISSUED Q D PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 �� 1 (Complete in triplicate) p 11 f Application i herebymade to the n J!aqLrin / '�"�' '� 'Local Health District for permit to-construct and/or install the work herein I described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wel3/pump and the Rules and RegulationlAf the San Joaquin Local Health District. „ Job Address Suubldi'vvision Name- V "� ✓� Owner's Name is �dtS ss. Y / 4AA AN �,• Pho Contractor's Nam 54�' 'r-4PIfo�fise No, �!.. Phon I' TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT r ¢ � ._ [] DESTRUCTION � + PUMP INSTALLATIDN SYSTEM}REPAIR Cl OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ri f � Ind ustrial � � en Bottom � Manteca Dia. of Well Excavation =f 7 O i mestic/Private �.•� Gravel Pack Tracy Dia. of Well Casing -_ �_ i] Public [ Other Delta [jIrrigation "A Approx. Type of Casing 4- •� pp Eastern r [f Specifications Cathodic Protection Depth P �- 1-7 Geophysical Depth of Grout Seal 8 � xLJ Type of Grout Other. � 2 Surface Seal Installed by,, .S L 0.4, e� f Repair Work Done ❑ Type of Pump f S H.p; •k7 State.Work Done / Well Destruction [J .W611 Diameter Sealing Material (top 501)'` tt Depth Filler Material (Below 501) I TYPE OF SEPTIC WORK: NEW INSTALLATION [ REPAIR/ADDITION U (No septic tank or seepage pit permitted ifpublicsewer is —�: i available within 200 feet.) - - Installation will serve: ,Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK [ Type/Mfg Capacity No. Compartments - PKG. TREATMENT PLT_ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ci Distance to nearest: Well Foundation Property Line i DESTRUCTION '! LEACHING LINE [ No, & Length of lines P Total length/size - FILTER BED Distance to nearest: Well Foundation Property Line l SEEPAGE PITS ❑ Depth Size Number _ SUMPS [i Distance to nearest: Well Foundation Property Line 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 j permit is issued, I shall not employ any person in such manner as to become subject to workman9 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 ll f all required inspections. Complete drawing on reverse side. { F Signed X Q 'S 42�p d` SA ATitle: Date: ° rz- FOR DEPARTMENT USE ONLY ? Application Accepted by _ Area (J J< 5tk - 466-6781 Additional Comments: -Q �- Lodi 369-3621 Pit or Grout Inspection b DateManteca 823-7104 Final Inspection by Date Tracy -835-6385 Applicant - Return all copies to: . Environmen al Health Permit/Services 160 E. Hazelton Ave., P.O. Sax 2009, Stk., CA 95201 �i • FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFD �t7s. C)S. o fOS,' �k �f.S,` a3�S�S �a9 j EH 13-24 REV. 10/82 10/82 500 14-26