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1.� APPLICATION FOR PERMIT y SAN JOAQLi% LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. T3 7 gp Telephone (209) 466-6781 DATE ISSUEDg� PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to const r t /o ins o herein described. This application is made in compliance with San Joaquin County Ordinance No. e e o 62 or well/pump and the Rules and Regul tions of the San Joauin Local Health District. Job Address — b� Subdivision Name^ Owner's Name \ �- e, ddress \Zb\lt • J T R__ Phone C)31-1(0077 J Contractor's Name cense No. Phone OQ TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑ Other ❑Delta T Irrigation pee of Casing Li 9 Approx. ❑Eastern Specifications ❑Cathodic Protection Depth ❑Geophysical Depth of Grout Seal Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) r- Installation will serve: Residence Commercial Other Number of living units: Number of bedroomsLot size 7 1 a UR/12d/ Character of soil to a depth of 3 feet: y4rll p Water table depth SEPTIC TANK Type/Mfg ('�,��tAJ Capacity 12.00 No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM iq. Distance to nearest: Well Foundation Property Line DESTRUCTION W LEACHING LINE ,�' No. 8 Length of lines 0 Total length/size IcAD FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS §' Depth Size 33�� Number -3 SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ (b 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 workmanIs 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 ap*POkcant mu f �all equi d ' spections. Complete wing on reverse side. Signed X Title: Dat FOR DEPA Application Accepted b Area �_ 1 ❑ Stk 466-6781 Additional Conine ' QLodi 369-3621 Pit or Grout In spe a Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copie to: Environmental Health Permit/Services 1601 zelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO _ X1-1 S o a Ai S EH 13-24 REV. 10/82 10/82 500 14-26