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4 APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT N0. 1601 E. HAZEL70N AVE., STOCKTON, CA Telephone (209) 466-6781 DATE ISSUED f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete.in Triplicate) Application is hereby madehto 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 and Regulations of the San Joaquin Local Health District. 1 S o Subdivision Name ,lob Address Z Phone Owner's Name A11 Al Address License :�:� �6� Phone q Contractor's Name �A 1 TYPE OF WELL/PUMP WORK: Il NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ e K� ��S� ~-i i t OTHER xll • "&'c47 n, 1 PUMP IFiSTALLATiON [] SYSTEM REPAIR ❑ ❑ � 1" DISPOSAL FLO. PROP. LINE _ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER WELLPITS/SUMPS Q1J FOUNDFOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing ❑ Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout Other Surface Seal Installed by 9 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction F-1 Wel li' Diameter Sealing Material (top 50') Depth Filler Material (Below 501) �- public Cy TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pryavailableewithiif nu200feet.) is Installation will serve: Residence _k Commercial Other / !, Number of bedrooms _ — Lot si e 7 Number of living units: Water table depth Q . Character of soil to aii,depth of 3 feet: Na. Gompartments SEPTIC TANK ❑ Type/Mfg N M -Capacity f ao PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ;?o No. & Length of lines Total length/size k - FILTER BED ❑ iL Distance to nearest: Well Foundation Property Line { M.Number k SEEPAGE PITS D Depth Size SUMPS ❑ Distance to nearest: Well Foundation Property Line._ DISPOSAL PONDS ❑4 I hereby certify that I'Ihave prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,ll nd 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 all not employ any person in such manner as to become subject to workman� compensation laws permit is issued, I shall of California." E Contractor's hiring sh subcontracting 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." The applicant ust call r all re fired inspect' n6s(J` Co ete dra}uin on reverse side. , r/ G 7 ��1, Date: a U Signed X �"' g� �I F DE 7 SE ONLY Area ¢_ ❑ Stk 466-6781 Application Accepted by ❑ Lodi 369-3621 f Additional Comments: 11 Date j� Manteca 823-7104 Pit or Grout Inspection by G 1�y i Date fe�"9 rJ Tracy 835-6385 Final Inspection by Applicant - Return all copies to: EnvironJJt1l Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., GA 95201 r ' I� FEE BASE If AMOUNT .DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO i 1, ( 10/82 500 " _ , EH 13-24 REV. 10821 .r / / 14-26 .