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` II APPLICATION FOR PERMIT ''A", SAN JOAQL;N LOCAL HEALTH DISTRICT i 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT NO. I Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IE (Complete in Triplicate) Applicatidh is hereby madeito 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 S Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules no R �ulayti s of the San aauin Local ] Distr Job Address !/ vJ hdivi� D Owner's Name Address Phone License No. Phone Contractor's Name ► : u h { TYPE OF WELL/PUMP WORK: NEW WELL F7 - WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER U r SEWER LINES 1 4Q 43 DISPOSAL FLD. PROP. LINE 1 DISTANCE TO NEAREST: SEPTIC TANK L C� ' FOUND"ATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industr' l } U Open Bottom Manteca Dia, of Well Excavation fmestic/Private IL❑ Gravel Pack F-]TracyDia. of Well Casing I Public If Other ❑ Delta Type of Casing _ 4 Irrigationi�. �.'AWrox:" (F � Eastern Specifications Cathodic Protection I Depth �q Depth of Grout Seal �,I j 17 Geophysical �o Type of Grout U Other I� " surface Seal Install d by i [.J i Repair Work Done �} Type of Pum _ H.P. 11 $tate Work Dane , Well Destruction U Well'�Diameter•"' Sealing Material (tap 50') - Depth — Filler Material (Below 50`) f � TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is i i available within 200 feet.) I 1 _ s' ( Installation will serve: Residence Commercial i Other Number of bedrooms Lot size ' r � Number of living units: � f Character of soil to airdepth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments EES PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM q° Distance to nearest: Well Foundation Property Line - DESTRUCTION I LEACHING LINE U ii No. & Length of lines Total length/size - FILTER BED I Distance to nearest: Well Fourdation Property Line SEEPAGEPITS F-1I� Depth Size Number i SUMPS L�i Distance to nearest: Well � Foundation Property Line DISPOSAL PONDS Ci ji II, i II F 1 hereby certify that I 'have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, 'land 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' icing or sub-contract g s gnatu certifies the following: "I certify that in the performance of the work for which this permi i issued, I shall empl sons s bject to workman's c ensation laws of California." The appan ust ca 11 o r i a e tions. Complete wi g on reverse side. Signed 'X Titl Date: � II. O ENT U NO � �f � Stk 466-6781 ) + Application Accepted b Area i " ,h f, Lod369-3621 T Additional^Comments: •-- 4 ��Manteca 823=7104_ Pit or Grout Inspection by ` .t p Date ❑ Tracy 835-6385 Final Inspection..rby - �I Applicants Return._al.l copie „ . on ental Hearth Permit/Sirvlale icesi:T6O1 E. .iHaze t iAveP:O. Sox 2009, Stk., CA 95201 _ . . T FEE BASE �I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO i� , cm. 10/82 500 EH 13-24 REV. 10/82I� 14-26 ��