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APPLICATION HEALTH D ' SAN JOAQUiN LOCALL HEALTH DISTRICT 1601 E. HAZELTON AVE.. STOCKTON, CA PERMIT NO. 43 - 1074 W Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - DATE ISSUED (Complete in.Triplicate) CA 1 Application is hereby made to the;San Joaquin Local Health District for a permit to construct and/or install the work herein p O described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump �1 and the Rules and Regulations the San Joaquin Lo' 1 ealth District, ti QrL Job Address 1 Z_ �4 Subdivision Name.. Owner's Name k 44 Address Phone �� Contractor's Nam Nf License No. 76�� Phone TYPE OF WELL/PUMP WORK: - NErI WELL REPLACEMENT ❑ DESTRUCTION❑ - PUMP INSTALLATION [{Y SYSTEM REPAIR /�F--lam OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLO.' PROP. LINE FOUNDATION :t �S "Y. AGRICULTURE WELL OTHER WELL/AOF4- PITS/SUMPS.;00 i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I❑ I atrial ❑Opel Bottom E]Manteca Dia. of Well Excavation /2—/4r.-,4stic/Private raSel Pack ❑Tracy Dia, of Well Casing /rHG ❑Publ{cG Other ❑Delta Type of Casing ❑ Irrigation 'j Approx. ❑Eastern Specifications — s (]Cathodic ProtectionDepth Depth of Grout Seal l.�f s (]Geophysical 1{ Type Of Grout CP IN k"` ❑Other ss`r/4 Surface Seal Installed by 4 &44!iO 7!. III Repair Work Done ❑ Type of Pum! II.P. 3 State Work Done 17•\�i\,, Well Destruction ❑ Well Diameter Sealing Material (Cap 50') Depth Filler Material (Below 60') TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ (No septic tank or seepage Pit permitted if public sewer is It 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 ❑ sType/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Type/Mig Capacity Method of Disposal SEWAGE SYSTEM ci Dist ante to nearest: Well Foundation Property Line DESTRUCTION i LEACHING LINE U NO.,6 Length of lines Total length/size FILTER BED ❑ Dist4e to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number - SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J I1 [ 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, [ Shall not employ any person in such manner as to become subject to worinant 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 appli ant mu 11 fora t ed inspections. Complete drawing on reverse side, 3 Sig Date: DEPARTME 5 w Applicat ccepted by' Area f2%JV. 03 ❑ Stk 466-6781 Additional Comments• L] Lodi 369-3621 Pito G ou al by las n Date 4s '�J [] Manteca 823-7104 FinInspection - Date �a <� ❑ Tracy 835-6385 Applicant - Return all copies ;b: Environmental Health Permit Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rFEFOE80.SEAHOUNb. .DUE .AMOUNT REMITCEIVED BY, DATE PERMIT N0.t`b I s s— EH 13-24 REV. 10/82 10/82 500 I 14-26