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is . � �/ g'�—•�� ,. APPLICATION FOR PERMIT .Q ' SAN JOAQL*N LOCALaHEALTH DISTRICT PERMIT NO, 5+ 1601 E. hAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 1 DATE ISSUED PERMIT EXPIRES1 YEAR FROM DATE ISSUED (Complete in Triplicate) ¢/} + T�� fora ermit to construct and/or instal i:4 biklherein„w Application is hereby made to-the San Joaquin Local Health District P described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. I862 for well/pump and the Rules and Reg lations of t San Joaquin Local Health District, a A11 1 �liyv.,� /r Subdivision Name Job Address ` �4/ Phone Address ! 1 Owner's Name r r License Na. Phone t7� ( Contractor's Name fir. r I{ TYPE OF WELL/PUMP WORK. NEW WELL WELL REPLACEMENT DESTRUCTION [J ?W OTHER ��ld1�� 1- `°"" PUMP INSTALLATION 0 SYSTEM REPAIR PROP LINE ' DISPOSAL LD. SEWER LINES PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK��. OTHER WELL FOUNDATION # AGRICULTURE WELL INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 n Bottom Manteca Dia. of Well Excavation l I� industrial Ue p{ _ .. .Dia. of Well Casing f omestic/Private '- "`�Gravel Pack- ' Tracy ,Public [j Other Delta Type of Casing Li Irrigation Approx. [Eastern Specifications Depth Depth of Grout Seal Cathodic Protection s Geophysical Type of Grout Other � Surface Seal Installed by T e of Pum H.P. State Work Done ►� YP P _f Repair Work gone � � 50'} Sealing Material (tap Well Destruction ❑ Well Diameter Filler Material (Below 50') Depth + No septic tank or seepage pit permitted if public sewer is t TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J ( available within.2D0 feet.) 4- y Commercial Other (I` installation will serve: Residence Lot size I Number of bedrooms `l Number of living units: Water table depth Character of soil to a depth Iof 3 feet: Capacity _-__�_ No• Compartments {- SEPTIC TANK � Type/Mfg Method of Disposal Capacity PKG.'TREATMENT PLT: 0 Type/Mfg Foundation Property Line SEWAGE SYSTEM Distance to nearest: Well DESTRUCTION kTotal length/size A LEACHING LINE U No. & Length of lines property Line �. ' Foundation FILTER BED;,, , � ❑ Y DiWell stance to.nearest: Depth �� Size Number SEEPAGE PITS ❑ P Foundation Property Line SUMPS L� Distance to nearest: Well DISPOSAL PONDS L7 I hereby certify that I have prepared t is a thenSanhJoaquinwLocalork 1Heall lthdDistrone nct�cordance with San Joaquin county ordinances, state.laws, and rules a g 411 certify that in the performance of the work for which this Home owner or licensed agent's signature certifies the following: permit is' issued, 1 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 followinensaticertify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's comp , � lican ust call f all required inspections, Complete dr wing on re er &A The app Date: Title: Signed X —� FO EPARTMENT USE ONLY �� Stk 466-6781 Area , — Application Accepted by r Lodi 369-3621 w 6 Additional Comments: � � Manteca 823-7104 Date i Pit or Grout Inspection by Date g ❑ Tracy 835-6385 l Final inspection by :J Applicant - Return all copies t nment, Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CR 95 � RECEIVED BY DATE PERMIT N0. FEE BASE AMOUNT DUE AMOUNT REMITTED 4 k INFO (� o� I b lS - D.3�1 �a / 10/82 500 F Eh 13-24 REV. 10/82 3 1 `E 5 14-26 -, rr