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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 L PERMIT N0, DATE ISSUED, PERMIT EXPIRES I YEAR FROM DATE ISSUED ta {Complete in Triplicate) Lodi 369-3621 Application is`hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein for No. 1862 for well/pump r described. This application is made in compliance with San Joaquin County Ordinance No. 549 sewage or Manteca 823-7104 and the Rules and Regulations of the San Joaquin Local, Health District. Date 'G Date Z Job Addres I r�4-LC�� C Subdivision Name "f Tracy 835-6385 A 'C_ � AFib' Phone >F'. E. Hazelton Owner's Nam Address t Phone%�.o�r� Bo x`2009, St k., CA Contractor' Name_ l9'J License No. 7 �� Frealth Permit/Services 1601 f TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION YSTEM REPA M OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD% PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom Manteca Dia. of Well Excavation Dia, of Well Casing ' U Domestic/Private Gravel Pack {Tracy 9r { ❑ Public f-1 Other Delta Type of Casing irrigation A rox. Eastern L 4 pp ❑ Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done 7� Well Destruction ❑ Well Diameter Sealing Material (top 501) — C Depth Filler Material (Below 50') r N REPAIR/ADDITION (,No septic tank or seepage'pit permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION L—I U available within 200 feet.)l Installation will serve: Residence _ Commercial i 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 f� PKG. TREATMENT PLT. Type/Mfg Capacity Method of.Disposal 1 " SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line s" DFSTRUCTION 3 t LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line. E SEEPAGE PITS Depth Size Number {! SUMPS IJ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ I [ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county t. ordinances, state laws, and rules and regulations of the San Joaquin Local Health in the p work for which this' "1 that in the performance Home owner or licensed agent's signature certifies the following: certify comof pensation in manner as to become subject to workman compensation ]aws of California." permit is issue I shall not employ any person .such the following: "I certify that in the performance of the work for which Contractor's r ng or sub -contracting ign7ture ertifies k ssued, I shall employ p rs As su 'ect to workman's c pensation laws of California." this permit The applic t }est call f all requi d spe .ions. Complete w n on everse side. i Title: Data' Signed x LY �� --Stk R PARTMENT 5E 466-6781 AI 1ition Acce ted by Area�,� PF p Lodi 369-3621 M Additional Comments: � Manteca 823-7104 Pit or Grout Inspection by Inspectidn by Date 'G Date Z Clinal Tracy 835-6385 E. Hazelton P.O. Bo x`2009, St k., CA Applicant - Return all copies to: Envirormertal Frealth Permit/Services 1601 FEE' INFO i SEH 13-24 14-26 w BASE AMOUNT DUE AMOUNT REMITTED I RECEIVED BY REV, 10/82 95201 DATE PERMIT N0. 10132 500 p