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APPLICATION FOR PERMIT SAN JOA%IN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, -Z Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED DATE ISSUED i (Complete it 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 is made in compliance with Sar Joaquin County Ordinance No. 549 for sewage or No. 1862 for wel3/pump and the Rules and Regulations of the San Joaquin Local Health listrict, / f- Job Address lV7 AAJ &C-r 40'-Su d'i'vision Name 6n v-$ Owner's Name i _ Address moi_ , f Contractor's Name�� f License No, Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U _ PUMP INSTALLATION SYSTEM REPAIR lL7 OTHER L� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE }� sw FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED-USETYPE,OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fIndustrial ' ,�{l� U Open Bottom-`-_F7 Manteca Dia, of Well Excavation U Domestic/Private Gravel Pack ❑ Tracy- k Dia. of Well Casing Public' ... 5.. L� . U Other Delta Type of Casing L Irrigation Approx. Eastern ,..., Specifications_ [� Cathodic-Protection• Depth Depth of Grout Seal ! Geophysical 1 Type of Grout Lf Other - Surface Seal Instal1ed-by :k Repair Work Done ❑ Type of Pump H.P. State Work Done /1 Well Destruction U Well Diameter Sealing Material (top 501): Depth Filler Material (Be.low 50') S TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITIC No septic tank or seepage pit permitted if public sewer is' available within 200 feet.) " Installation will serve: Residence Commercial _ Other ? tr Number of living units: �_ Number of bedrooms ,Lot size L7 3C13'�C ) Character of soil to a depth of 3 feet:' Water table depth / /.j SEPTIC TANK Type/Mfg��j(,�, fk J_5C,4Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity', Method of Disposal SEWAGE SYSTEM Distance to nearest.:. Wel] ��.__FoundationJ roP perty Line DESTRUCTION F '`> LEACHING LINE No; .& Length of lines .� '] J. Total length/size 4SW/P l -FILTER BED Distance to nearest: Well ,(�� Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Di-stance to nearest: Well Foundation Property Line DISPOSAL PONDS' - I I hereby certify that I have prepared this,application and'rthat the work will .be.done in accordance with San"Joaquin county } ordinances, state laws, and rules and regulations of the San ecaquin Local Health District. , Home owner or licensed agent's signature certifies the following:,''I3certify,tKit 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 hir'ng or sub-contra4ed ture certifies following,"'I certify-that in the performance of the work for which this permit is sued, I shall emsubject td'work n's compensation laws of California:" P The applican 11 f all-rections: -Cnmple_ e d rr reverse side. ai-` •y, .� Signed X I> Title Dater FOR DE TMENT-USE ONLY, £,. Application Accepted b r ''Area 046 Stk 466-6781 Additional Comments: i r'' Ej Lodi 369-3621 3 Pit or Grout Inspection by I ;'' Date'. Manteca 823-7104 % Final Inspection by ' i Date �—t--"-/ Tracy 835-6385 Applicant - Return all copies'to: Env on°mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201., ..� FEE BASE AMOUNT DUE n AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ' INFO LH 13-24 REV. I0/82 T °1"V T 10/82 500 ' 14-26V c Y? Q� `]Lt ij F(�iW7icfG;}j7� x