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APPLICATION FOR PERI)i T SAN 30AQUiN LOCA! HEALTH DISTRICT M 1601 F. HA7ELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-5761- DATE ISSUED PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicare) 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 sewage or No. 1862 for well/pump ; and the Rules and Regulations of the San Joaquin Local Health District. Job Address Subdivision Name Owner's Name g(f Address Phone II Contractor's,Name IJ 10A C License No. Phone I TYPE OF WELL/PUMP WORK: NEW WELL ]ell WELL REPLACEMENT ❑ DESTRUCTION ❑ IX PUMP INSTALLATION i SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK .lLalu- SEWER LINES Z /+ DISPOSAL FLD.,0j/jJ:2ffg_PRDP. LINE D FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE AF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONST !J 4Ind trial -- -•- pen-Bottom-'-O-Manteca ""�°•�Oi�a':'�df"Wel l-Extavation�- omestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public ❑ Other ❑ Delta fr irri ation Type of Casing � F 9 Approx. ❑ Eastern Specifications Cathodic Protection Depth .. 1-1-Geophysical •�....rDepth of Grout Seal 4 Type of Grout Other Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done i Well' Destruction ❑ Well- Diameter `7 Sealing Material j(top, 50') Depth Filler Material (31 5D'} TYPE=OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ' r f1k Y 1. available within 200 feet,} 'Installation will serve: Residence _ Commercial 0t he r, �F -Number of living units: Number of bedrooms Lot size �� I Character of soil to a depth of-3 feet: E Water table depth 1£� u SEPTIC TANK E Type/Mfg t Capacity No. �Compartments i ;a PKGTREATMENT PLT. ❑ Type/Mfg Capacity Metho'of-Disposal SEWAGE SYSTEM ' Distance to nearest: . Well Foundation Property;Line DESTRUCTION ❑ �' 7 LEACHING LINE �,..-•U- ..No,�&-Leng.th.of 1-i.nes- - ---�- Total length/size FILTER"BEO ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS "^ Depth Size - - e •Number -,. .. .- SUMPS f U 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ;;°.: e 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-s•i•gna-ture-certi-fi•es the-fol-lowing: "I certify that in the performance of the work.1for which this permit is -ssued, I shall play persons subject to workman's compensation laws of California.' The applic t s call for 1 requi ed inspections. Complete,draw' g on `rrvverse side.] Signed X- — F ' NT%tle. f - ��liluf� - Date: FOR DE+ RTMENT U$E ONL F €�€ s A lication Accepted by Area ❑ St 466-6781 Additional Comments-, Lodi 369-3621 Pit or Grout Inspection by Date7 ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies VVEn1140nrrental Health Permit/Services 160 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, Ll INFO Q�, -�).-7 4 EH 13-24 REV. 10/82 `_ /13710172 500 14-26