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S APPLICATION FOR PEC ' SAN JOAQL;': LOCAL iiEA.LTH JiSTRICT 1601 L. HAGCLTON AVE., STOCKTON, ck Telephone (209) 466-67x1 PE 11, PSUEE)D� PERMIT EXPIRESPiRES 1 YEAR FROM DATE ISSUED DATE (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, 1852 for well/pump and the Rules.andRegulations of the,San,loacuin-rL-oca-l-Hea.lthfDistrict. Job Address — 64 _ -- -- Owner's NameP —:- ss Contractor's Name License N6. Phone TYPE OF WELTIPUMP WORK: dEW",WELL`'✓�} WELL REPLACEMENT � DESTRUCTION LJ PUMP INSTALLATION SYSTEM REPAIR L7 OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK/U(J-,�Ff— SEWER LINES DISPOSAL FLD. '� PROP. LINIE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial Open Bottom " U p anteca Dia. of Well Excavation 2160mestic/Private ' 1�<ravel Pack Tracy Dia, of Well Casing —�jJ 42 1-1Public .Other Delta Lj Irrigation ��Q?► pDeType of Casing _ Cathodic Protection Depth Eastern Specifications Geophysical Depth of Grout Seal _ +� ISE LJ Other Type of Grout �E�LlltllJT Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') V Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (_l REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is Installation will serve:: Residence _ Commercial _ Other available within 200 feet.) ,} Number of living units: a Number of bedrooms Lot size Character of soil- to.a depth of-3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments !!! PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS �j Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line '' DISPOSAL PONDS 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 workman$ compensation laws of California." Contractor's hiring or sub-c6ntracting 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 applicant us ca for 1 required inspections. Complete draohg on r erse e Signed X_ Title: Da .,. Date: FO TM T USE Application Accepted by i Area b EJ Stk 456-6781 Additional-Comments: - Lodi 369-3521 i pit or Grout Inspection by DateW7 El Manteca 823-7104 Final Inspection by:i° Date Ej Tracy 835-6385 Applicant - Return all Copies to. ' Environmental Health Permit/services1601 E. Hazelton Ave., P.O. Box 2009, Stk. CA 95201 I` FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO LH 13-24 REV, 10/82 I0/82 500 14-26