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APPLICATION FOR PERM: SAN JCAQU"IN LOCAL,HEALTH DISTRICT 1601 E. HAGELT.CN AVE,, :STOCKTON, CA PERMIT NO. Tel ephne_(209)�166-^678i // //� DATE ISSUED !J'"/(1`Oy 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is hereby'made to 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 sew"CrjoQiA2 for well/pump i and the Rules and Regulations of he aa in Local Healt District. J� ��-- Job Address7W 9 Q ivision Name Owner's Name Address ,� Phone S 7 - Phone + Y [r I !� Contractor's Name License f TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [1- DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR (I OTHER LJ / DISTANCE TO NEAREST: SEPTIC TANK --�-SEWER LINES SQ� DISPOSAL FLO. PROP. LINE _ 9 'f Y �• r 1 FOUNDATION AGRICULTURE WELL OTYER'4cLL _�n PITS/SUMPS �..[NTEND1D ,l1SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J ustrial rI Open Bottom Manteca Dia, of Well Excavation J�eof� mestic/Private ^Gravel Pack Tracy Dia. of Well Casing Q] Public 'Other _ _-.._y'DeltaP`G Type of Casing _ -i/Irrigation Approx. Eastern Specifications _ AO M Cathodic Protection Depth ' Depth of Grout Seal [L Geophysical 11 N Type of-Grout ES f U Other �, Surface Seal Installed by / ` '�_ ' s Repair Work Done D Type of Pump h.P• P --�' State Work Done / 1{, U � Well Destruction � Well Diameter Sealing Material (top 50') w .j Depth Filler Material (509{,50+.) �� J - TYPE OF SEPTIC WORK: NEW INSTALLATION Li REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted' if public sewer is available within 200 feet.) Installation will server Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water Capacity ! No. Commtable'de th _ Ca ents+ SEPTIC TANK U Type/Mfg p y part PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal ! �� m f SEWAGE.SYSTEM ❑ Distance to nearest: Well Foundation Property tine n?9 DESTRUCTION v k 4 LEACHING LINE U No. & Length of lines Total length size 1 1 FILTER BED 1--] tine Distance to nearest: Well Foundation -Property , ' SEEPAGE PITS ❑ Depth Size Number SUMPS l—1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ � _ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county „ I 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." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the yior for w ch this permit �s ed I shall e 1 p ns subject to workman's compensation'laws of California." � 1 The appl - ant- u 11 for a inspecti s. Complete draw' on rev Ade. Signed it �` Date: i Application Accepted by D E ONLY Area EJ Stk� 466-6781 Additional Comments- [� Lodi 369-3621 v��4 W -.-Pit or Grout Inspection byDate _� � Manteca 823-710 ■u.r� Final Inspection by Date Ej Tracy --- O� V y1v ` Applicant - Return all copies to: ironmental Health Permit/Services 1601 E. Haze]to Ave., .P.O. Box 2009, Stk., CA 95 f T DUE AMOUNT REMITTED RECEIVED 3Y DATE ,r PERMIT NO, FEE BASE AMOUNT � INFO O I �1(� 3- � -4 _ 10182 Eh 13-24 REV. 10/82 * EY 14=`25