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APPLICATION FOR.PERM,IT SAN JOAQU'N LOCAL H7ALTH DISTRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) „ Application is hereby made to the San Joaquin Local Health District for permit tc 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 Regulations of the San Joaquin Local Health Di.strict. Job Address �"S�O E_G vim-$ Subdivision.Name Q r Owner's Name fj/1fJQ SE Address i4QV�/il! 7�7 " Phone. Contractor's Name QN WEW14(1WT License No. 3:7619,--z Phone, 7 TYPE OF WELL/PUMP WORK: NEW WELLE fi WELL REPLACEMENT � DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR U OTHER DISTANCE TO NEAREST: SEPTIC TANK _ J?,:�, SEWER LINES DISPOSAL ,FLD.I /_W PROP.-LINE 3-5- FOUNDATION .SFOUNDATIONS AGRICULTURE WELL 8�_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II J Industrial Open Bottom D Manteca Dia. of Well Excavation /;?1/F/.QST S�/ Domestic/Private Gravel Pack L Tracy Dia, of Well CasingPublic Othe W Delta irrigation Type of Casing ;��-4_ Li 9 Approx. Eastern Specifications Cathodic Protection .� Depth _ Geophysical a Depth of Grout Seal �Q Type of Grout Sj jC C��f//FiVT 640aT` fJ Other { _„.3urface Seal Installed by (514-50 t lal'VIO ( 1 Repair Work Done G Type of Pump S��• H.P. State Work Done Well Destruction U Wel 1 Dfameter 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 Number of living units: Number of bedrooms Lot'size # Character of soil to a depth of 3 feet: / Water table depth SEPTIC TANK CI Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal n SEWAGE SYSTEM DESTRUCTION ' Distance to nearest: Well Foundation Property Lire DE ❑ � $ LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line F SEEPAGE PITS C Depth Size Number SUMPS L_I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C - 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. F 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 fallowing: "I certify that in the performance of the work for which 1 this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant ust call or 'Il u ed inspections." Complete drawing n reverse side. Signed X Title: -�_Z;4 _ Date:. . 7- FOR g FOR E MEN USE ONLY i 1 Application Accepted by Area �k 456-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection b 7 f P Y _ ate � Manteca 823-710410�/,}��4..�. P� � '� inal Inspection by �- Date �, c L Tracy 835-6385 ` Applicant - Return a.1T-Acopie5 to: Environmertal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ¢ FEEINFO - BASE AMOUNT DUE AMOUNT REMITTED, RECEIVED BY DATE PERMIT NO. I r fi If s7� Tis EH i3-24 REV. 10/82 �' O g�_la 10/82 500 14-26