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y APPLICATION FOR PERMIT S5N JOAQCiN LOCAL DISTRICT 16CI E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 1 Telephone (209) 466-6781 j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 k described. This application is made in compliance with San Joaquin County Ordinance No, 549 for sewage or No. 1862 for well ump and the Rules and Regulations of the �/San Joaquin Local Health District. /` _� 0 W Job Address o K,JC��• MIP\ P,\Pg6 Subdivision Name �O Owner's Name rnw Address �O 9,6 ftrn4n-reA W6 3) Phone TlS�G57a� � Contractor's Name a bthp-V License No. 2-7 Phone 5 Z q- 75/.3 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION i AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open ;Bottom. ❑Manteca Dia.-of Well Excavation L] Domestic/Private' ❑ Gravel' Pack Tracy Dia, of Well Casing ❑ Public ❑Other.I ❑ Delta irrigation Type of Casing L i 9 Approx. ❑ Eastern L Depth Specifications t ❑Cathodic Protection � Depth of Grout Seal ❑Geophysical Other Type of Grout. Surface Seal Installed by F Repair Work Done ❑ Type of Pump p H.P. State Work Done (� Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth t Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITION E) (No septic tank or. Seepage pit permitted if public sewer is — 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 A Capacity. No. Compartments j }i PKG. TREATMENT PLT. ❑ Type/Mfg 'I Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION I d LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ ' Distance .to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance .6o nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - 1 z 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 wgrkmant 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 applicart.must c r all require spections. Complete drawing or reverse side. C 1 Signed XTitle: V c°6 Date: ool R FPARTMENT SE Ai -&,.� / Applica ion cc Vb&y 1�li2 a 6 ❑ Stk 466-6781 A Additional Comments: 7��O11 ❑ Lodi 369-3621 r Pit or Grout Inspection by Date anteca 823-7104 Final Inspection by p, Date ?v ' Tracy -835-6385 a Applicant - Return- all cop to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEE BASE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT NO. INFO -JA I if EH 13-24 REV. 10/821n 11Q�p 10/82 500 14-26 .