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. .:.' . APPLICATION FOR PERMIT SAN J0.4QU'i:2 LOCAL ii-�ALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. — f w-14 Telephone (209) 466-6181 _ DATE ISSUED PERMIT EXPIRES 1:YEAR FROM DATE ISSUED (Complete in Triplicate) :.�--Appiication is hereby made to"the"San t.oaquin 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 N and the R les and Regulations of the San Joaquin Local Health District. -� Job Address C Subdivis.ion game i ane Address Phone F Contractor's Name �- > � : License No. Phone 411 I TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �.�,� PUMP INSTALLATION (❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROF. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L ❑ Industrial mw.. U,Open`80ttom- 0 Manteca Dia;—of Well—Excavation— 4 • - UDomestic/Private GravFe l Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑ Other ❑ Delta 1 u' Irrigation Approx. ❑ Eastern Type of Casing r\ ❑ Cathodic Protection Depth Specifications 1.16 ❑Geophysical .Depth of Grout Seal N r� Type of Grout U Other C Surface Seal Installed by Repair Work Done ❑ T pe of Pump --HP. ,a State Work Dane$— Well Destructionll Diameter ,' —Sealing Material (top 50') Cc V.,e,- 1 "'''A ti , �. Depth �t�-Filler Material (Below 50') I� 3 TYPE',OF-SEPTIC WORK: NEW"INSTALLATIONLI yREPR'IR/ADDITION ❑ (No septic,-tank or-seepage pit permitted if public sewer is --,available within 200 feet.) . Installation will serve: Residence_ Commercial _ Other 4 » Number of living units: Number of bedrooms Lot size i Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. T e Mf ❑ yp / g - Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation PropertyjLine DESTRUCTION LEACHING LINE ❑ No, & Length of lines Total length/size FILTER BED Distance}to nearest:j Well Foundation PropertylLine SEEPAGE PITS - Depth I' SiZe"Ir Number SUMPS ❑ Distance to nearest:N Well r 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 jules'and.regulations of the San Joaquin Local Health District. a Home owner or,'Iice_nsed•agent's,signature certifsies'thetfol 1owing; "I certify that in the performance of the work for which this permit is issued, I shall-66t -employ any,person in—s'ch'manner as to become subject to workmanIs compensation law's of California." Contractor's hiring ors =ccontracting=signature-certifies.the:folhowing: "I certify that in the performance of the work for which this Aermit is is ILWal.[ s sons ubject to workman's compensation laws of California." The appli 1 equ' i ctions., Complet4dri on revers side.,Sign Titles Date:_FOR R T USEON Application Accepted by `� Ge,�J�-Area _ I Stk 466-6781 Additional -Comments: ❑ Lodi 369-3621 Pit or,G rout Inspection by Date ,: Manteca 823-7104 r Final Inspection' by Date iL Tracy. 835-6385 ' r Applicant.-.,.Return all copies nvironmenta.l—Health,P-ermit/Services 1601 E. Hazelton Ave., 420. Box 2009, Stk., CA 95201 ' R IFEE ASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ,( INFO I� EH 13-'24' REV. 10/82 f PA CV At, r S7 10/82 500 f 14-2b �/