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r` r APPLICATION FOR PERMIT SAN JOAQUitl LOCAL HEALTH DISTRICT PERMIT N0. 1601 E. 4A-ZELTON AVC., ST�OCKTON, CA Telep�hcne,l209) 466-b78i DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete it Triplicate) rein eninit to l the w Application is sapplication ppli at the Sa' th istrict for a CountypOrdinance cNo. 549ifordsewagesorlNo. 1862rforewell/pump described. ?his app ' and Rules and Regula � J �uin Lo 1 alth District. tions of the S. i' Subdivision Nan* Job Address Phone r Address phone Owner's Name - License No. •—�` Contractor's Nane ' WELL REPLACEMENT DESTRUCTION J j TYPE OF WELL/PUMP WCRK: NEW WELL OTHER U I PUMP INSTALLATION SYSTEM REPAIR / PROP LINE SEWER LINES DISPOSAL FCD. DISTANCE TO NEAREST: SEPTIC TANK ` OTHER WELL PITS/SUMPS N FOUNDATIOAGRICULTURE WELL —ter k - �- f CONSTRUCTION SPECIFICATIONS INTENDED 'JSE TYPE OF WELL PROBLEM AREA Z #47lJ' U Open Bottom Manteca Oia. of Well Excavation Industrial O{a, of Well Casiig Public Domestic/Private ravel Pack Tracy ?Other Delta Type of Casing Lj Irrigation Approx. Eastern' Specifications Cathodic Protection I Depth Depth of Grout Seal � Geophysical Type of Grout r U Other Surface Seal Installed by _ I IQ H P State Work Done _ Repalr''dork Done U Type of Pum 1 Sealing M-ti- 5C')i_(top 1 Well destruction G Well Diameter Filler Material (below 501 _ Depth f REPAIR/ADDITION L; (No septic tank or seepage pit permitted if public sewer is Z TYPE{OF SEPTIC WORK: NEW INSTALLATION E1 available within 200 feet.) s Other �� i (" In'stailation will serve: Residence f Commercial _ ' Lot size 1 f Number of bedrooms Water table depth Number of living units: y Character of soil to a depth of 3 feet: ,. Capacity _� No. Compartments.`_ i `_� - SEPTIC TANK Type/Mfg _.Capacity Method of Disposal PKG. TREATMENT PLT. n Type/Mfg �, A Foundation Property Line i _- I SEWAGE SYSTEM Distance to nearest: Well Cl DESTRUCTION " ' Total length/size LEACHING LINE �� No, & Length of lines ____ — — Property Line ' + Foundation FILTER BED !� Distance to nearest: Well __�---- Sine { Number (` OeQth �. Property Line SEEPAGE PITS J ----- Foundation ` SUMPS �� Distance to nearest: Well DISPOSAL PONDS ❑ i • ne in accordance with SanJoaquin county I hereby certify that I have prepared this application and that the work will be do ordinances, state laws, y erforrance of the work for which this and rules and regulations of the San Joaquin Local Health District. ertif in such manner as to become subject to worknanK compensation laws of California." Home owner or licensed agent's signature certifies the following: 1 certify that in the p I permit is issued, I shall not employ any p l Contractor's hiring or sub-contra empleygpersonsusubject�toeworkman�s}compensationrlaws ofCalifornia." of the work far whit this permit is issued, I s o reverse side. f The appli ant mus 11 fo all r ed inspections. Complete ora i g � Date: itle: I Signed _ S- 466 81 f FOR ART t� USE ONLY -y area Q Applicati Acc ted by Lodi 369-3621 r�,Additional Go ?nts: ____ .Manteca_823-7104. . mm Date. on !- Tom- ...-1,/ racY:.�835-6385- -- -pit or Grout-Inspecti •bY T .-•Date-�_Q;�S� �Y---.- ina"1�IPspecCio>i'by'� Applicant - Return all copies j o: Environm tal Health permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952 01 DATE PERMIT NO. AMOUNT REMITTED ,-p RECEIVED BY loS W i FEE BASE AMOUNT DUE a 4 gy- iNFO r - 10/82 500 EH 13-24 REV. 10/62 "^"--