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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT PERMIT N0. 1501 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) rein onstruc an /or intal the Application is licationoishmadeninocompliancelwithlSanHeathDJoaquin Countype dinancceermit tocNo. 549tfordsewagesorlNo. 1862rforewell/pump described. Thissappapp and the Rules and Regulations th an Joaquin Local Health District. Subdivision Name ` Sob Address ►1 Phone te ) Address "i Owner's Name' Phone .License No. Contractor's Name �]�_ Lt! , NEW WELL DESTRUCTION TYPE OF WELL/PUMP WORK: ❑ WELL REPLACEMENT ❑ LJ OTHER PUMP INS7ALLATIDN �SYSTEM REPAIR ❑ LJ PROP. LINE SEWER LINES DISPOSAL FLO. W DISTANCE TO NEAREST: SEPTIC TANK _+� OTHER WELL _-��_ PITS/SUMPS FOUNDATION AGRICULTURE WELL � CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL PROBLEM AREA Dia. of Well Excavation Industrial U Open Bottom ❑Manteca ((� E1<15omesticlPrivate E] Trac Gravel Pack ❑ y Dia. of Well Casing V L❑ Public ❑Other ❑ Delta Type of Casing V Irrigation Approx. Eastern Specifications � ❑ Depth Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout U Other �2 s� urface Seal Installed by Type of Pump __�H•P• .J 3C tate Work Done Repair Work Done ❑ yP Well Destruction F-1 Wei l Diameter v Sealing aterial (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [JREPAIR/ADDITION ❑ (No septic tank or seepage pit permitted public within200feete) is installation will serve: Residence — Commercial Other Number of bedrooms Lot size _�,� Number of living units: Water table depth Character of soil to a depth of 3 feet: No. Compartments �T e — .Capacity SEPTIC TANK - y--❑ ypMf/ g Capacity Method of Disposal �_.._ PKG. TREATMENT PLT. ❑ Type/MfgFoundation Property Line SEWAGE SYSTEM Distance to nearest: Well DESTRUCTION Total length/size LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Well Foundation Property Line Depth Size Number ' SEEPAGE PITS ❑ P property Line SUMPS ❑� Distance to nearest: Well Foundation DISPOSAL PONDS ED t the work will be done I hereby certify that I have prepared this application and tharaccordance with San Joaquin county District, f ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distri ' 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 workmanK compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issue I shall employ persons subject to rkman's compensation aws}vf California." y c� The applicant must c 1 for all re it d inspec ons. o pl a dr wing on a Date: le: Signed X USE ONLY FOR Area 1-y \ �5tk 466-6781 � Application Accepted by U Lodi 369-3621 Additional Comments: Date 17 Manteca 823-7104 Pit or Grout Inspection by Tracy 835-6385 �� Date %�l�� Final Inspection by 201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95 RECEIVED BY DATE PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED 1 INFO A 5 a_Js 10/82 500 FH 13-24 REV. 10/82 14-26