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APPLICATION FOR PERMIS SA JOAQL'iN LOCAL HEALTHiISTRICTs 1601 E. HAZELTON AVE., STOCKTON, CA A Telephone (209) 466-6781 PERMIT NO. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUEDWW i (Complete in Triplicate) R Application is hereby made to-the San Joaquin Local Health District for a Permit to construct and/or install the work herein 1 described. This application is made in compliance with San Joaquin County Ordinance No, 549 for sewage or-No. 18i and the Rules and Regulations of t e Sa Joaqu' cal Health District. 62 for well pump Job Address 6 Subdivision Na Owner's Name Addressy� _1G00 Phone Contractor's Name License No. _ Phone TYPE OF WELL/PUMP WORK: NE4! WELL Q WELL REPLACEMENT ❑ DESTRUCTION❑ } PUMP INSTALLATION ❑ SYSTEM REPAIROTHER 0 W k DISTANCE TO NEAREST: SEPTIC TANK ❑ SEWER LINES DISPOSAL FLO. PROP, LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q/ ,� • 1� Industrial ❑Open Bottom Manteca ❑ Dia. of Well Excavation V L;Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing ❑Public ❑Other []Delta LjIrrigation Approx. Eastern Type of Casing w ❑ I ❑Cathodic Protection Depth Specifications i ❑Geophysical Depth of Grout Seal �j 1 LJ Other Type of Groat 1 r--� Surface Seal Installed by 0 i Repair Work Done l r Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth tiller Material (Below 501) TYPE Of SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ (No septic tankor seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet_) Number of living units: ,tNumber o bedrooms. Lot size a.�o . .•r " Character-of soil to'a'depth of 3 feet: Water table depth SEPTIC TANK }r Type/Mfg L Capacity��,�1 'No, Compartments PKG. TREATMENT PET. ❑ Type/Mfg Capacity Method of Disposal est: W SEWAGE SYSTEM Distance to nearell th Foundation Property Line t�u DESTRUCTION ❑ {� LEACHING LINE - LJ No. & Length of lines Total length/sit FILTER BED �{ Distance to nearest: Well E d Foundation Property Lin -PAW'* s SEEPAGE PITS ❑ Depth Size Number .SUMPS L4l Distance to nearest: Well Foundation Property Line iL DISPOSAL PONOS ❑ _ •^ 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county Y 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-contracting signature certifies the following: "I certify that in tAe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The ap lic ust call for all required insrections. Complete d ing an reverse side. Sign X Title,; Date: 00-377 Appli tion Accepted b " TMENT USE ONLY Area Stk 466-6781 Additional Comments: [ Lodi 369-3621 Pit or Grout Inspection b Date -l❑ Manteca 923-7104 Final Inspection by Date �7,t tI Tracy 835-6385 Applicant - Return all copies to:, E�vir men Health Permit/Services 160 E, Hazelton Ave.. P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTEDt RECEIVED BY INFO DATE PERMIT N0, EH 13-24 REV. 10/82 n p_ 4l-- __S 10182 5DO {