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N "JAW i APPLICATION FOR PERMIT I n I Uk I SAN JOAQUIN LOCAL HEALTH DISfi II;f C� 1601 E. HAZELTON AVE., STOCKTON, CA ;EB „ ! c; 19,s3 PERMIT NO. F Telephone (209) 466-6781 .l),{i.li LOCAL DATE ISSUED It PERMIT EXPIRES 1 YEAR FROM DATE I�is-�l�.T�-� DISTRICT. (Complete in"Triplicate) Application is hereby made to thJ 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. 3862 for well/pump r and the Rules and -Regulations of the San Joaquin Local Health District. / Job Address Q�,��%� Owner's Name Address _ Phone Contractor's Name � ,�,/j %['� _License No. � ( i >i Phone TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ± SEWER LINES DISPOSAL FLO. PROP. LINE S FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C>6 INTENDED USE TYPE OF WELL ❑Industrial - .. ,.Open ,Bottom Domestic/Private ❑ Gravel Pack ❑ Public ❑ Other U Irrigation Approx. ❑ Cathodic Protection . Depth '4 Geophysical # L•l Other Repair Work Done ❑ Type of Pump Well Destruction ❑ Well Diameter Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS Manteca-;4.Daa•:ofWel1YExcavation -� - ❑ Tracy Dia, of Well Casing ❑ Delta Type of Casing ❑ Eastern Specifications - Depth of Grout Seal Type of Grout Surface Seal -Installed by H.P. State Work Done Sealing Material (top 50') Filler Material (Below 50') TYPE OF SEPTIC WORK:, NEW INSTALLATION ❑ REPAIR/ADDITIONJX (No septic tank or seepage pit permitted if public sewer is i available within 200 fe6t.) Installation will serve: Residence ! Commercial Other Number of living units: /j j Number of bedrooms^ Lot size Character of soil to a depth of 3 feet: ,MAwa4e Water table depth SEPTIC TANK Type/Mfg g:r/j` C� Capacity f ® ® No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line W d r SEEPAGE PITS ❑ Depth I Size Number �..--SUMPSU-Distancento�nearest: 'Wel'l—" Foundation " Prop -e tY-Cine DISPOSAL PONDS ❑ ' r 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." Cantractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit -is -i sued, I shall employ persons subject to workman's compensation laws of California." The-appllcant mfulst call for all required inspections. Complete drawing on reverse side. ` Signed X / 1Title: Date: FOR DEPARTMENT USE ONLY --� Application Accepted by ,1� "fAty1 Area E] Stk 466-6781 42 Additional Comments: ❑ Lodi 369-3621 ° Pit or Grout Inspection by Date � Manteca 823-7104 Finai Inspection by ,( V R h Date ��Tracy 835-6385 Applicant - Return all copies to; Environmental ii alth Permit/Services 1601 E. Haze on Ave., P.O. Box 2009, Stk.,,CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED ECEIVED BY DATE PER N0. ' . INFO All. 44 3 �3 g EH 13-24 REV, 10/82��.� 10/82 500 �! 14-26