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Y. APPLICATION POR PERN67 SAN JOAQLiN LOCAL 'HEALTH DISTRICT 1601 E. HA2ELTON AVE., STOCKTON, CA PERMIT No. Telephone (209) 466-6781 F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in'Triplicate) Application is hereby made to the San Joaquir• Local Health District for a permit to construct and/or install the work herein --t described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weTl/pump and the Rules and Regulations of the San Joac0 n Local alth District. R Job Address Subdivision Name Owner's Name ddress , Phone Contractor's Name icense No. Phoned 7 . TYPE OF WELL/PUMP WORK: NEW WELL �� WELL REPLACEMENT DESTRUCTION v PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER DISTANCE TO NEAREST: SEPTIC TANK -_� SEWER LINES ,Q 0 �!� f DISPOSAL FLD. I&Q :f7 PROP. LINE +^ FOUNDATION AGRICULTURE WELL r OTHER WELL PITS/SUMPS INTENDED JSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -gl - ndustria..l- .. .. - — p ._ ^x ., w � -- !a G�,., ;�. - - • +.: I" J r -- -0 enTBotti5m--^-Q Marite�a Dia, of"We 1-1�Ex'cavat 'n (�� —r � omestic/Private; Gravel Pack ❑ Tracy Dia, of Well Casing r i Publico � Other Delta p,ilrr.igation Type of Casing Approx. Eastern Cathodic Protection ., Depth Specifications Geophysical Depth of Grout Seal )Other i Type of Grout #] Surface Seal Installed by Repair Work Done Type of Pumpr IV H.p 7--l ' State Work Done Well'Destruction Well Diameter , tt- "� sof U _ "�_ Sealing Materl (i p 5D ) Depth �f_� Flier Material'oel6w(50') fir{ TYPE OF SEPTIC WORK:. NEW INSTALLATION U REPAIR/,ADbl-T.ION [D (No sept-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 El Type/Mfg Capacity No. Compartments r' PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ��--tt Distance to nearest: Well DESTRUCTION _ Foundation Property Line F r LEACHING LINE U No. & Length of lines Total length/size x.V -w,7-ts,1 , FILTER BEDDistance to nearest; Well Foundation Property Line .w: J '�-+• i +_ { T .SEEPAGE p1TS Depth -��...;.�-.p w- Size Number SUMPS El Distance to nearest: Well Foundation t Property Line' +� DISPOSAL PONDS �� ,-- -,� .w _ , �,, f4 r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county s l 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 V 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 following: "I certify that in the performance of the work for which this permit is issued, I shall employ sons subject to workman's compensation laws of California." The applicant m call for all req insp ctions• Complete draw i g on r erse side. Signed X " e; I > Date: ' FO E ARTMENT U ONLY Appl ation Accepted by Area Q�f• Stk 466-5781 4 Additiona Comments: Lodi 369-3621 Pit or Inspection by to - g Manteca 823-7104 , Final Inspection by Date ' ❑ Tracy -835-6385 , Applicant - Return all copies to: Environmental 111,1th Permit/Services 16 1 E. Hazelt Ave., P.O. Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUEL a AMOUNT REMITTED RECEIVED BY DATE PERMIT ND. INFO LH 13-24 REV. 10/82 10/82 500 14-26