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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL•PEALTH DISTRICT 1601 E. MAZELTON AVE., STOCKTON, CA PERMIT NO, 11 3 LIQ61 Telephone (209) 466-6781 DATE ISSUED S o2 a PERMIT EXPIRE$ i YEAR FROM,DATE ISSUED (Complete in Triplicate) r Application is hereby madeito they San Joaquin Local Health District for a pemlt'to construct and/or install the work hereir, 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 ndRegula io f th n Joaquin Local health District. Job Address a _ Subdivision Name _ (�"q Owner's"Name Address Phone _ ContrattOr`5 Natae t, License No..i Phone TYPE OF WELL/PUMP WORK: 4VA WELL BELL REPLACEMENT..C]. 'DESTRUCTION ] 7 c� PLOP INSTALLATION [] SYS1EM REPAIR"'w17 3 OTHER F7 DISTANCE TO.NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE X TYPE OF WELL PR03LEM AREA_ CONS'RICTION SPECIFICATIONS O 17 Industrial 10 Open Bottom 0 Manteca Dia. of Well Excavation U bamstic/Private 40 Gravel P k FiTracy _ _ Dia. of Well Casing � LJ Public g(J Other (�Delta T ^ ype of Casing - L_i Irrigation Approx. C3 Eastern • Specifications _ 0 Cathodic Protection Depth Depth of Grout Seal z 3[]Geophysical Tyae of Grout Ocher S3 Surface Seal Installed by 4Repair Work Sona-D. Type bf-Pump— '"'- H,P, --State'Rork'DbiiS"'"",- 'Well Destruction [� Well Diameter i Sealing Material (top 501) - y Oepthmj . I .s i Filler Material (Below TYPE OF SEPTIC,WORK. NEW nsTACLATION I REPAIR/ADOITION ri_J+(No septic tank orlseepage�pit permuted If public sewer is I { , available within 200 feet') Installation will server Residence I Commercial Other Number ofiliving units: Number of bedrrxxns -Lot sire so Character Character of soil to a•d'e th of 3 feet: i " ... _ meter table depth SEPTIC TANK LL Xype/Mfg Y` Capacity NO. Compartments ! PKC. TREATI{ENT PLT. yType/ttfg Capacity Method of Disposal ? SEWAGE SYSTEM r', Distance to nearest: Well Foundation Property Line DESTRUCTION . t LEACHING LINE r4-1?a: b Length of lines ) +] ;r� Total length/size Y FME0BED �, 'Distance to nearest: Well Foundation Property Line SEEPAGE PITSp Ipth Size 'ber SUMPS t_..1 Distance to nearest:, Well Foundation .- Property Line _ DISPOSAL PONOS .... r. 1 hereby certify tiiat I halve prepared this application and that the work will be done in accordance with San Joaquin county oroinances.'state laws. and rules and regulations of the San Joaquin Local Health District. iiwrs owner or licensed agent's signature certifies tie following "I certify that in the performance of the work for which this permit is issued, I shall not,emptoy any person in such manner as to become subJect"to•workmant compensxti0n lass of Ca�ifOrnia." Contractor's ?miring or suh-contracting signature certifies the °ollowing: "I certify that in the perforrunce of the work for which this permit:is issued, 11 shall employ persons suoject to workman's compensation laws of California." i Tiq app ~mu3 a fo 11 uir sp tions. .Complete,d wing an revers side. Sign Title: i a OE T;ENT USE fJh.Y -3-may„'Z [D Stk 466-6781f Application Accepted by, _ tsHtr#✓ " Area 7 j Q Additional Comments: Lodi 369-3621 # 7104 ; Pit or Grout Inspection Ca Lr. ' ..__ L_; Manteca 823- . -7&e � � J ] Tracy 835-6385 Final Inspection b� g Catc __.. ... Applicant Return all copies to: Environmental Health PQrmit/Services 1601 E. Har.elton Ave.. P.O. Box 2OOg, Stk.. CA 95201 FEE -LI BASE ,-"AM01R'iT DUE V AMOUNT REM:TTE3 RECEIVED BY DATE-� 4ER}4l7 NO INFO EH-rl-24 REV. 10/87 1 10182 SOO 14-26 -�39 S ( si