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APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT 1601--;E-. HAZELTON AVE., STOCKTON, CA PERMIT NO. ' Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in 'Triplicate) 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 i.s' made in com liance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules aan/n}}d �� t Regulations h San quin Local Health District. co Job Address CJS f71 Subdivision Name Owner's Name Address Phone co L Contractor's Name / Licerse-No. 1 �/. l'/ Phone -� s. TYPE,bF WELL/PUMP WORK: 'NEW WELL WELL REPLACEMENT DESTRUCTION Y PUMP INSTALLATION SYSTEM REPAIR LJ OTHER "DIS7,ANCE TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE " FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS �. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS c J Industrial U Open Bottom Manteca Dia, of Well Excavation 'A' I UtDomestic/Private Gravel Pack Tracy Dia. of Well Casing P.,ubl is •_�' � 7-1 Other L] Delta. Type of Casing ' �'LjI ,rigation Approx. D Eastern Specifications ',Cathodic Protection Depth r s' Depth of Grout Seal 'D,Geophysical Type of Grout IJ Other 4` Surface Seal Installed by Repair Werk'Dohe,�j ~Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ a ` Depth Filler Material (Below 50') ' 4-TYPE OF SE PTIC.'&K: NiW 1NSTALLATICN ❑ REPAIR/ADDITION �j' (No septic tank or seepage pit permitted if public sewer is S available within 20C feet.) a Installativn,:ral ser.ve: Residence _Commercial _ other Number of ]i.v!�ing units:. Number of bedrooms Lot size ' :,. Character of_a '.i•1 to a depth of 3 feet: x Water table depth SEPTIC TANK i. ...4 Type/Mfg Capacity No. Compartments PKG. TREATMENT.iPLT% Type/Mfg Capacity 4 Method of Disposa)- (y.} 11. SEWAG£-SYSTEM x:T Distance to nearest: Well �yadation Property Line 4_ - DESTRUCT IOkrj LEACHING LINE' No.x11 Length of lines Total length/size j ..,b ) FILTER BED *a1 ] Distance to nearest: Well Foundation Property Line n I SEEPAGE PITS Depth Size Number �1 SUMPS � '" I 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. 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 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 must all for all quired -inspectp'qp.. Complete drawing on reverse sidj� ` ? Signed X.: Title: `Q� ��i _ Date: / I DE NT U5 LY Application Accepted`y� Area 5tk 466-678 Additional Comments -. [--] Lodi 369-36 1 Pit or Grout Inspection by Date LL] Manteca 823-7104 Final Inspection,,4by x: Date L Tracy 835-63$5 •'' Applicant -',Return all _eo,pies to: n ronmental H h Permit/Services 1601 Ha el ton Ave., P.O. Box 2009, Stk., CA 95201 - FEE BASE i -Am DUE AMOUNT REM[TT ED !RECEIVED BY DATE PERMIT NO. INFO:. � ��: Gam' 1�`► yi` �`'�� '�� EH 13-24 REV. 10/82 10/82 500 14-26 �'��