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- APPLICATION FOR PERMYT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 6� - �! Telephone (209) 466-6781 4 '' DATE ISSUED I�PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein 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 yHealth District. TM Job Address 79 86 hi,>$� e Subdivision Name Owner's Name 4SW%&,V" ,T^ AddressPhone��d `ra-®1670 Contractor's Name License No. 2 Phone RKOAqy.�? CA TYPE OF WELL/PUMA WORK: NEW WELL (] WELL REPLACEMENT ❑ DESTRUCTION F-1 ) PUMP INSTALLATION SYSTEM REPAIR OTHER 0 ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS z INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' i] Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private 71 Gravel Pack Tracy Dia. of Well Casing Public 4 [j Other Delta Irrigation s Type of Casing 9 Approx. []Eastern 4 - Specifications Cathodic Protection Depth Depth of Grout Seal ' Geophysical Type of Grout Other Surface Seal Installed'by °9 ) ' Repair Work Done EJ- Type of Pump a H.P. State Work Done f Well Destruction LJ ,Welk Diameter Sealing Material (top 50') a I Depth Filler Material (Below,50')-- ' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ].°(No septic tank or seepage pit permitted'if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial _ Other ' Number of living units: —/— Number of bedrooms Lot size— Y Character of soil to a depth of 3 feet: SAAN LOAM Water table depth ®�® SEPTIC TANK Type/Mfg apacity / No. Compartments PKG, TREATMENT PLT, Type/Mfg Capacity Method of Disposal a Distance to nearest; Well 160",f-Foundation 2 CO Property Line LEACHING LINE No. & Length of lines 3 90' Total length/size /0-)L D ' FILTER BED Distance to nearest: Well 106,"-Foundation 3 0' Property Line /V A SEEPAGE PITS Depth . ® Size ;Z;:k �k 'Z S Number SUMPS L J Distance to nearest: Well ,�Foundation �&9 1 Property Line ' DISPOSAL PONDS a' 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•Cal ifornia, Contractor's ' ing or sub-contracting si ature certifies the following: "I certify that in the performance of the work for which this permit _is ed, I sha employ pe ons subject to workman's compensation laws of California," The app nt ll fo all req a ins{Y�tions. Comple dr i'i on reverse side. ' rA Signed Title; / Date, P y �Q IC.7- FP,A NT USE ONLY Application Accepted b ��1� Area Stk 466-6781 Additional Comments: t--)— ❑ Lodi . 369-3621 Pit:or frpetit-Inspection by I Date 0 Manteca 823-7104' Final Inspection by Date 0 Tracy 835-6385 Applicant Return all copies to: Environmental Health PeiIt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' FEE BASE AMOUNT. DUE AMOUNT REMITTED s RECEIVED BY DATE PERMIT N0. INFO t Eli 13-24 REV, 10/82 1 10/82 500 14-26