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r APPLICATION FOR PERM SAN JOAQUiN LOCAL. HEALT H ICT �� J 1601 E. HAZELTON AVE., STOCKTON, cA'jPERMIT NO. $� � is Telephone (209) 466-6781 Q PERMIT EXPIRES 1 YEAR FROM OATSA��JJOAQUIN LOCAL DATE ISSUED U �..7 S. tort 4r,ete in Triplicate) RULTIS DISTRICT Application�is hereby made to the San Joa uin 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. 'M62.for well/pump and the Rules and Regulations of the Sa Jo in L 1 He lth Pistrict. Job Address �� division Name Owner's Name 'w / r Address ` � �= /�lrti� r/ue.�`.. Phone �DU� Contractor's Name Cg 1Wd e)__ &=111phe License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION r� , PUMP INSTALLATION F-] SYSTEMREPAIR L] OTHER LJ" DISTANCE TO NEAREST: SEPTIC TANK-_JSfj SEWER LINES � � DISPOSAL FLO. fS�fi#- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� C Industrial F-1 Open Bottom Manteca Dia. of Well Excavation 1 3 Lf 1 I LJ Domestic/Private Gravel Pack Tracy Dia, of Well Casing � Public • L� �Other ] Delta Irrigation Type of Casing LV 9 L4rIO. Approx. Eastern ` v P r Depth Specifications 16 M Cathodic Protection P Depth of Grout Seal 1-1 Geophysical �� - k / Type of Grout �-04:ZZ1411 p I6 VOther 1u-4#y 4mu-,4. ..�Joaly +� Surface Seal Installed by Repair Work Done F-1Typeof Pump H.P. State Work Done L Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage"pit permitted if public sewer is �. available within 200 feet.) i 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 r Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ EACHING LL INE' '^U No. &'Length of-lines - _ Total length/sizer. +- �` FILTER BED Distance to nearest: Well Foundation Property Line E SEEPAGE PITS ❑ Depth Size Number k SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS e 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-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." i The applicant ttst ca 1f 1 required inspections. Complete dra ing on reverse side, q Signed X z— ,. Title: _ _ Date: — !`� SPU DEPARTMENT USE ONLY Application Accepted by _-C/- _ Area Stk 466-6781 'y Additional Comments: V Lodi 369-3621 Pit or Grout Inspection b Date ❑ Manteca 823-7104 Final Inspection by Date ' Tracy 835-6385 Applicant - Return all copies to: EnvironmXtfl Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT RFMITTED RECEIVED BY DATE PERMIT NO. INFO -— „-,_;.—ai— T rte- � # O (7 EH 13-24 REV. 10/82 10/82 500 y, 14-26