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= APPLICATION FOR PERMIT SAN JOAQUI N LOCAL HEALTH DISTRICT -q3 - 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 17 -1 - Telephone (209) 466-6781 •' DATE. I$SUEO PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �A (Complete in Triplicate) Application is hereby made to thel an Joaquin Local Heiilth District for a permit to construct and/or install the work herein described. This application is ma8e in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wel.11pump and the Rules and Regul ions, of the San Joaquin Loca Health 4i strict. Job Address_1 ij,�� Subdivision Name Owner's Name Zn,:e Address. JPhone &M!'-{JiF_940 Contractor's NamLicense No. s .C�%'9,r2,/� _ _ - Phone, 'tea e 2?✓�7 TYPE OF WELL/RUMP WORK: NEWWELL i' WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR U OTHER DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPCISAL FLO. PROF. LINE __ T FOUNDATIONAGRICULTURE WELL OTHER WELL PITSJSUMPS INTENDED USE -_ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 industrial FOpen Bottom -,`[J Manteca Dia. of Well! Excavation 54 Domestic/Private Y Gravel Pack- .` SeTracy Dia. of Well Casing A �17 Public��ri�+�117 �j Othe�pprox. 0 Del to Type of Casing 1149*7 Lj Irrigation AEastern k ❑ .. Specifications _ ,._ U Cathodic Protection Depth �^ ' al - Depth of Grout Se_ Geophysical Type of Grout U Other.. Surface Seal Installed by Repair'Work Done G Type- of Pump 41ii,P State Work Done r./1 iPe�rli�C.i Wel INDesiruction U Well Diameter; Sealing Material (top 50') _ Depth _ w� ;X Filer°Material (Below 50') TYPE OF kEPTIC WORK: NEW INSTALLATION U REPAIRJADDITION J (No septic tank or seepage pit permitted if public sewer is r , ; available within 200 feet.) Installation will serve: , Residehce- • iw CoTW.ercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK tl E_j Type/Mfg} a Capacity No. Compartments-,-=�"' PKG. TREATMENT PLT. E] Type/Mfg { • _ Capacity Methoddf'Dispoul SEWAGE SYSTEM -4, -� Distance�tolnearest: Well Foundation- F,.-�';" pProperty Line DESTRUCTION,"-��- LEACHING"LINE` 1J No. teng�f�ldnes`•-" Total length/size FILTER REO tiisfan a to nearest: Wel 1 Foundation Property Line SEEPAGE PITS Depth i Size ___ ,Number SUMPSIn istanc. to nearest: Well Foundation Property Line U ' �Distand. . . DISPOSAL PONDS ED I hereby certify that I have prepared tris application and that the work will be done in accordance with San Joaquin county "-ordinances, state laws, and�`ruleVard regulations of the San Joaquin Local Health District. home owner or licensed agent's signature certifies the followings "I certify that, in the performance of the work for which this permit is issued, I shall not employ any parson In" such manner as to became 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 sha41 employ persons subject to workman's compensation laws of California." The appl ican a "call, al I eegtuir j in 69p ions Compr ete drawing b:54rsA 'side• Signed X ' Lti'�i✓r Title Date: FO DEP ENT USE ONLY -7 Application Accepted by ,�v Area 407 ❑ Stk 466-6181 i`••Additional Comments: _ Lodi 369-3621 Pit or Grout inspection by�4401 Date �[,�€ _ U.. Manteca,823-7104.,�.,:. Final Inspection by _ Date _ ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1661 E., Hazelton .Ave„ P.O. Box 2009, Stk., CA 95201 FEE SF AMOUNT DUE .,..r _ "AMOUNT�REM1TTfD RECEIVED BY DATE NO. [NFD 21—i VPERMIT �i--- EH 13-24 REV. 10/82 ' ; .. , 10/82 500 14-26 '