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- r APPLICATION FOR PERMIT � J ' SAN JOAgUIN LOCAL HEALTH DISTBP, � A 14 1601 E. HAZELTON AVE., STOCKTON, CA PERFIIT NO, `l Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSr vr,1 -1CVL.I''1 �"UCA1 DATE ISSUED (Complete in-Triplicate)�. ... EN—TH DISTRICT 003-cS'a r 33 Application is eIyClmg to the San Joaquin LocalHealth District for a permit to construct and/or ", .t�rk herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for se age or No. 1862 for wel /pump"n and the Rules and Regulations of the San Joaquin Local Health District, 4V , _ Job Address Subdivision Name $ J Owner's Name Address j C L/ Phone Contractor's Name License No. 160Q Phone ?_ TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public F-1 0ther Delta Type of Casing Irrigation Approx. [-] Eastern Cathodic Protection Depth Specifications Depth of Grout seal Geophysical Type of Grout �1 Lf Other Surface Seal Insta led b Repair Work Done X Type of Pump Ft.P. 19 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50`) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j (No septic tank or seepage pit permitted if public sewer is y available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION Q LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS FI Depth size Number SUMPS LJ Distance to nearest: Well Foundation Property Linn DISPOSAL PONDS L 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. 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 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 shall employ persons subject to workman's compensation laws of California." The applicant ust call r all equi ed inspections. Comple drawin o reve se s'de. ��jj Signed K ` a" Titl ate: ,e VX DEPARTMENT U GLY Application Accepted by Area Q�_ Stk 465-67$1 Additional Comments: odi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date 7__7_ V e/L Tracy 835-6385 Applicant - Return all copies o: Environmental aith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO L — r EH 13-24 REV. 10/82 10/82 500 14-26 i