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F APPLILATiON FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. ( - 1 K Telephone" (209) 466-6781 / I DATE ISSUED — PERMIT EXPIRES 1 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 No. 1862 for well/pump and the Rules and R g 1 ti %fj�e t,54iL_�.oaqUin�ocalAea)th District. ' Job Address ��/// Subdivision"Name Owner's Name Address ;3'' Phone Contractor's Name /f License No, ' „ Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ED 1 PUMP INSTALLATION rp�SYSTEM REPAIR ❑ OTHER ❑ -� DISTANCE TO NEAREST: SEPTIC TANK !_ SEWER LINES /G O r}� DISPOSAL FLD. PROP. LINE 4;- FOUNDATION �� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation rOf/ G LY Domestic/Private "' i LJ �avel Pack ❑Tracy Dia. of Well Casing lQ flC Pfu'b ❑Other ❑Delta r Irrigation Type of Casing U 9 Approx. ❑ Eastern Cathodic Protection Depth Specifications Depth of Grout Seat -.5-04 Geophysical Ov// /! Type of Grout Other ❑ � ��S ssrface Seal Installed by K Repair Work Done Type-of Pump 4C_ H.P. 140 to Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ \ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑.. (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ 'Commercial Other i Number of living units: Number of bedrooms -Lot size Character of soil to a depth of 3 feet: Water table Hepth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal EWAGE SYSTEM o Distance to nearest. Well Foundation' Property Line �+ ' DESTRUCTION LEACHING LINE ❑ No. & Length of lines a Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line S PAGE PITS ❑ Depth Size Number 6 PS ❑ Distance to nearest: Well Foundation Property Line f O YOSAL PONOS [] 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." jContractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which chis permit is issued. I shall employ persons subject to workman's compensation laws of California." The applicant must call or i1 required inspections. Complete drawing on reverse ISA9ned X -^ - le: `` Date: 'F DEP TMENT USE ONLY Application Accep by Area ❑ Stk 466-6781 Additional Comments: / /I! -ES_Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ❑ 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 0 I 2, � it�-�� EH 13-24 REV. 10/82 10/82 500 14-26