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f I APPLICATION FOR PERMIT /gs SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 ,Y PERMIT EXPIRES 1 YEAR FROM PATE ISSUED DATE ISSUED i (Complete ir-Triplicate) Application is hereby made 'to the San Joaquin Local Health District for a permit to construct and/or install the work herein I� I 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 Regulations of the San Joaquin Local Health District. G �JaJ Job Address ,77 d -L D Subdivision Name Owner's Name 177QElla Address Z Q 14( _ ` Phone 366- 7,3SJ' Contractor's Name "A MiniAn�apr}Ilem Drilling C*Mense No, Phone 0 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE '4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED_USE.,- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS x17 Industrial � � ppen'Bottom '"Q Manteca' Dia, of Well Excavation /0 Domestic/Pr,ivate U . - ...& .,[ Gra vel •Pack Tracy Dia. of Well Casing /(J Ll Public Other r Delta Type of Casingr2� �j Irrigation Approx. ❑ Eastern Depth Specifications i Cathodic Protection p Depth of Grout Seal f Geophysical Other Type of Grout ` I Surface Seal Installed by Repair Work Done Type of Pump -urhj1,e- H.P. 319 State Work Done f Well Destruction U Well Diameter Sealing Material (top 50') _ Depth 3-5-0 Filler Material (Below 50') I! TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION j j (No septic tank or seepage pit permitted if public sewer is 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 Distance to nearest: Well "Foundation Property Line DESTRUCTION .' LEACHING LINE J No. & Len th.of lines,f Total length/size ( FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS C1 Depth V Size Number T SUMPS l—j Distance to nearest: Well Foundation "`Property'ti'ne— • P, DISPOSAL PONDS rl I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county j ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Name 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's compensation laws of California." Contractor's'hiring"o'r sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issu shall employ persons,subject•Ito workman,'$Lcompensation laws of California." The applica s cal for all requiree. inspections. Complete drawing on reverse s id e. p Signed X Title: �b c�pDate: Z 9'JOY EPARTMEN U ONLY S Bi�)' Application Accepted by (/✓ AFea d/ Stk 466-6781 { Additional Comments:. X,Lodi 369-3621 p s Pit or Grout Inspection by Date a Manteca 823-7104 Final Inspection by Date "v L Tracy 835-6385 Applicant - Return all copies to: Environmental H 7th Permit/Services 1601 az e3 ton Ave., P.O. Box 2009, Stk., CA 95201 Tis FEE BASE AMOUNT DUE _ AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. f INFO EH 13-24 REV. 10/82 10/82 5D0 14-26 I M