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TYPE OF WELL/PUMP WORK: NEW!WELL F-1 WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM -REPAIR U ,.. OTHER F-1 DISTANCE TO NEAREST:_5EPTIC TANK __.-_ ___. _ SEWER L'INES,_! _f ly___ �DTSg05AL,.FLD.. __ _. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE J Industrial Domestic/Private Public V Irrigation F-ICathodic Protection LLj Geophysical Other TYPE OF WELL U Open]Bottom Gravel Pack EDOthe' 4 Approx. bepth Repair Work Done L Type of Pump Well Destruction U Well Diamete Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS Manteca Dia. of Well Excavation [] Tracy_R Dia._of_Well.-Casing Delta Type of Casing Eastern Specifications Depth of Grout—Sed-1 ~-- Type of Grout % Surface Seal{Installed by- H.P. y-H.P. State Work Done Sealing Material (top 50') { Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW APPLICATION FOR PERMIT .. or seepage pit permitted if public sewer is SAN JOAQL;N LOCAL HEALTH DISTRICT a available within 200 feet.) Installation 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.3- � Other Number of living units: Telephone (209) 466-6781 DATE ISSUED Character of soil to a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (_.,._Water table depth SEPTIC TANK (Complete in Triplicate) Capacity ' 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 anda ulations of the San Jo uI LLoocal Health District. Job Address i J Subdivision Name [J Owner's Name _ __- :Total-length/size Address Phone Contractor's Name Distance to nearest: Well License No. d g �� Phone TYPE OF WELL/PUMP WORK: NEW!WELL F-1 WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM -REPAIR U ,.. OTHER F-1 DISTANCE TO NEAREST:_5EPTIC TANK __.-_ ___. _ SEWER L'INES,_! _f ly___ �DTSg05AL,.FLD.. __ _. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE J Industrial Domestic/Private Public V Irrigation F-ICathodic Protection LLj Geophysical Other TYPE OF WELL U Open]Bottom Gravel Pack EDOthe' 4 Approx. bepth Repair Work Done L Type of Pump Well Destruction U Well Diamete Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS Manteca Dia. of Well Excavation [] Tracy_R Dia._of_Well.-Casing Delta Type of Casing Eastern Specifications Depth of Grout—Sed-1 ~-- Type of Grout % Surface Seal{Installed by- H.P. y-H.P. State Work Done Sealing Material (top 50') { Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATIONU REPAIRI,ADDITIO (No septic tank or seepage pit permitted if public sewer is I a available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth oC 3 feet: (_.,._Water table depth SEPTIC TANK Type/Mfg Capacity ' o. Compartments PKG. TREATMENT PLT. F-1Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundations. Property Line DESTRUCTION LEACHING LINE [J No. & Length of lines _ __- :Total-length/size FILTER BED Distance to nearest: Well Foundations Property Line SEEPAGE PITS Depth 1_ Size ';_l XX KI 0 Number SUMPS Distanceto nearest: Well Foundation ¢ Prbperty Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will b,e'done in accordance with Sdns,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 Ahat 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 workmans 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 ermit is issued, i shall employ persons subject to workman's compensation laws of California." �✓ The applz mu t cal for all quir i pections: ;Complete wing o reverse ide. d Sig " Title:. Date: 0 FOR D ARTM NT USE ONLY'�`�� / �s Application Accepted by ii _ .If Brea VS/ r9c 5tk 465-6781 Additional Comments* Pit.or Grout Ins Final Inspection by Applicant - Return all s to: Environmi FEE BASE AMOUNT DUE INFO th Permit/Services1601 E. Ha REMITTED RECEIVED BY-' �[ L di '3 3 U ca Tracy 835-6385 tone Ave., P.O. Box 2009, Stk., CA 95201 DATE PERMIT NO. EH 13-24 REV. 10/82 �1 10/82 500 14-26