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APPLICATION, FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT $ 3 " —7 b� " 1601 E. HAZFLTON AVE., STOCKTON, CA Telephone(209) 466-6781 PERMIT NO. DATE ISSUED I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Z7 $3 'r. � t(Complete in�Triplicate) Application is hereby made to the San Joaquin Local Health District for a described. This application is made in compliance with San Joaquin Count permit0 dinanccecNo, 549tfordSewagesoalNo. 1862l the rforewell and the Rules ard.Regulations of the San Joaquin Local Health District. y 9 /pump Job Address 266. W. 'Manilakl Rd Moises Subdivision. Name i'I Owner's Name Eddie QiSes �. Address, 266 W. Maml a Contractor's Name Clark Wel' Phone W License�No, F Phone ! TYPE OF WELL/PUMP WORK: NEW-WELL ®C WELL REPLACEMENT L] DESTRUCTION ❑ 6Q PUMP INSTALLATION SYSTfM�REPAIR ❑ OTHER ❑ ; 6 r DISTANCE TO NEAREST: SEPTIC TANK -}'J 00 t SEWER LINE DISPOSAL PLO. PROP. LINE FOUNDATION II AGRICULTURE WELL OTHER WELL F PITS/SUMPS � INTENDED USE TYPE Or. WELL PROBLEM AREA! CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑Manteca Dia., of Well Excavation 10 3/411 { !J Domestic/Private Gravel PackTrac �y, ❑ Public � y k Dia, of Well Casing p L]Other Delta pIrrigationApprox. F-] Eastern Type of Casing . 188 Steel F—ICathodic Protection Depth Specifications {!! ❑Geophysical k Depth of Grout Seal ! ❑Other Type of Grout I� Repair Work Done Surface Seal Installed by C lEi r k [J— Type of Pump P, State Work Done ' l t Well DestructionWell Diameter Sealing Material (top 50') Depth Filler Material (Below 50') f� TYPE OF SEPTIC WORK: NEW INSTALLATION EJ- REPAIR/ADDITION. ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence_ Commercial Other available within 200 feet.) e Number of living units: Number of bedrooms f (, 4 Lot size , Character of soil to a depth of 3 feet: a`M Water table depth s� SEPTIC TANK E] Type/Mfg b ! Capacity No. Compartments aJ( PKG. TREATMENT PLT. Type/Mfg SEWAGE SYSTEM Distance tCapacity Method of Disposal � DESTRUCTION ❑ Disto'nearest: Well Foundation Property Line :f p LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance tolnearest: Well I: Foundation Property Line " SEEPAGE PITS ❑ Depth Size p Number q7 SUMPS EI Distance to`nearest: WellFoundation Property Line DISPOSAL PONDS ❑ I . 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 wort: for which this permit is-issued„I shall not a oy any person in such manner as to become subject to workman compensation laws of California." Contractor's hiring or su - r n sign ure certifies the following: "I certify that in the performance of the work for which this permit su , I al pers subject to wor`kman's compensation laws of California." The appli st r pections, Complete drawing on reverse side. r Signed X FOR pEPART Title': Date: 26 u1 v SZ Application Accepted by Area ❑ Stk 466-6781 AAditional Commen jS ❑ Lodi 369-3621 Pit or Grout Ins :tion by N Date ❑ Manteca 823-7104 Final Inspection by Date i`� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Perrlt/5ervices 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE l AMOUNT REMITTED. RECEIVED BY DATE PERMIT NO. INFO )) -7 f EH 13-24 REV. 10/82 r:!6 3 w X10/ 500 14-26 4.