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i APPLICATION FDR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E_ HAZELTON AVE., STOCKTON, CA PERMIT N0. i Telephone (208) 466-6781• DATE IssuEo PEP. iT 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 work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or io. 1862 far well/Dug-7 i and the Rules and Regulations of the.San Joaquin Local Health District. Job Address (F&-Subdivision Name Owner's Name rn G Address O Phone Litense No. Phone contractor'sildff�e ! .t TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION❑ PUMP INSTALLATION [] SYSTEM REPAIR ❑ OTHER ❑ (�` DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO- PROP_ LINE Vi"- F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA�` CONSTRUCTION SPECIFICATIONS 1:3Industrial • ❑Open Bottom '❑:Manteca Dia. of Well Excavation ` { {Domestic/Private ©Gravel Pack ❑Tracy Dia. of Well Casing ❑public ❑Other �.JDelta Type of Casing i Irrigation Approx. []Eastern Specifications Depth❑ Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout I CJ Other Surface Seal Installed by Repair WorK Done❑ Type of Pump H.P. �StcCtrl7-rk Done Well Destruction.❑ i?ell Diar"ter Sealing Material (top 50') — Death Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAI DDITIO (No septic tank or seepage pit permitted if public %ewer is ❑ — -U vai able within%•20A feet.) 6_7installation will serve: Residence Cm mrcial Othf ftLerber of li' .ng ..nice/ Numhar 4f bedrooms Lot six Character of soil to a depth of 3 feet: _ Water table de�th T �r - - Capacity9/�� . - SEPTIC TANK 1�3 Type/Mfg ` s _ No. Compartments .� PKG. TREATMENT PLT. (� Type/Hfg city Method of Disposal SEVAGE SYSTEM ❑ Distance to nnarncr.-_ tJell dl w.> G AFound ion Property Line � _* DESTRUCTION LEACHING LINE LJ '` No. & Length of lines = Total-lengtki/size FILTER BED ❑ Distance to nearest: Well Foundation _.�__ Property Line ' SEEPAGE ftTj Mtii ,Ly •CiTP [• � Number SUMPS l_.a _ Distance to nearest: well•1�Foundation A0 ProVerty Line DISPOSAL PONDS ❑G(.C7-1L- �Y �lr�O�ir�. /LrI` dz�z- I herehy rgrtify that 1 have prepared this apolicaticn and that the ,cork will be done'in accordance with San Joaquin county ordinancesw state laws, and rules and regulations of the San Joaquin Local Health District. 1 Home owner or licensed agent's sivnature 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 workman5 compensation laws of CalifOrnia." Contractor's hiring or sub-contracting signature certifies the folloainp;oll-certify that A n.the perforrdance of the•±rork for which s this permit is issued, I shall employ persons subject to workman's compensation laws-of-Califomila."` The applicant m t Egli for ail t sired inspections. Compl—e- drawing on'Me laNse side. ' ,uy� Title: Date: 9f!Z Signed K� s� FOR DEPAR T SE ON Y ❑ App7icatior Accepted b • nr Stk 465-67$1 Additional Comments: 00_�_ [et» j Lodi 369-3623 . . Pit 4r Grout Inspection b Date ❑ Manteca 823-7104 �" f ,.. Final Inspection by Date ^[] Tracy 835-6385- i Applicant - Return all copie to; Environmental Health Ppf,,WServfees 160 E._tta2elton Ave., P.D. Box 2flDg. Stk„ CA 952D1 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY II DATE PERMIT NO. INFO y � if �� f Ex 13.24 -REV. 10/82- 10/$2 500 14-26