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APPLICATION FOR PERMIT - N LOCAL HEALTH DISTRICT �3 / 1601601 E.E. HAZHAZELTON AVE., STOCKTON, CA PERMIT N0. y Telephone (209) 466-6781 DATE ISSUED / _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 9q,5 0 �( ,. . /I_ - (Complete in Triplicate) 6. 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 Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations oft e San Joaquin Local Health District. Job Address -��Y'\_v., Name V Owner's Mame Address Phone Contractor's Name . �J�j_(�\"�'�{�\ License No. ..'�S" / Phone V TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT. ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom Manteca Dia, of Well Excavation -U Domestic/Private Gravel Pack Tracy Dia. of Well Casing - 1-1 Public ❑Other E]Delta T ypeIrrigation pec of Casing U 9 Approx. �Eastern Cathodic Protection Depth Specifications EJ Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') i ` TYPE OF SEPTIC WORK: NEN INSTALLATION EJ REPAIR/ADDITIONo septic tank or seepage pit permitted if public sewer is - - - " - Installation will serve: esidence %--Commercial Other availableWithin 200 feet.) Number of living units: Number of bedrooms Lot size - ` Character of soil to a depth of 3 feet: 0 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE No. & Length of lines + X tj'0 Total length/size FILTER BED Distance to nearest: Well Foundation Property Line r SEEPAGE PITS Depth Size Number SUMPS F:r' Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D16 K iI' .JC —w`(\ C,.-Ijs 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 Lqcal Health District. Hone 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 California." ntractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which t ennit is issue I shall ploy persons subject to workman's compensation taws of California." The apple t st call f all quer ins ec tions. Completed wing on re ers _ o��f Sign Title: Date:2� FOR D ENT USE'ONLY Application or by Area Q) Stk 466-6781 Additional Comments: F-1 Lodi 369-3621 Pit or Grout Inspectionn b& Date ❑ Manteca 823-7104 Final Inspection by `C lrrrvr....� Date lb-a-1-83 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO •• EH 13-24 REV. 10/82 .�.In ( 1_ (l n„ _ 10/82 500 14-26 l/�� vLIX)6✓�