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[�'�� APPLICATION FOR PERMIT _ � �, SAN JOAQUiN LOCAL,HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, �CA PERMIT NO. Telephone (249) 466.6781 DATE ISSUED [n 1 13 PERMIT EXPIRES 1.•YEAR_FROM DATE ISSUED i (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 described. This application is madelin compliance with San Joaquin County Ordinance No, 549 for sewage or-NO.-. 1862 far well/pump and.the Rules and Regulations-of theSanJoaquin Local Health District. Job Address Subdivision Name Address r Phone Owner's Name Phone 1 Contractor's Name u��p License No. Z��7fo _�L.t'��1� 6. - TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION ❑ GJ PUMP INSTALLATION�M+�SYSTEM�'REPAIR►- OTHER ❑ I SEWER LINES DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC,TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL , INTENDED USE TYPE OF WELL' PROBLEM AREA: CONSTRUCTION SPECIFICATIONS - Industrial ❑ Open Bottom ❑ Manteca 'Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy" - Dia.. of Well Casing F t ❑ Public ❑OtherDelta❑ ! Type" of Casing Lj Irrigation Approx. •❑ Eastern Specifications r ' ❑Cathodic Protection Depth, Depth of Grout Seal ❑Geophysical i a. - - Type of Grout € Other - ! Surface Seal Installed by g. Type of Pum H.P. State Work Done Repair Work Done ❑ TYp P � Well Destruction ❑ Well Diameters Sealing Material (top 50'}. - r : V Depth Filler Material (Below 50') sewer TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION .❑ (No septic tank or seepage piavailableewithinU200cfeet.) is ^„ I Installation will serve: Residence *#"" Commercial _WOther t Ipp Lot size f� Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: OF No. Compartments SEPTIC TANK Type/Mfg �' - Capacity 17 t7� _ Line SEWAGE Capacity Mety hod of Disposal PKG. TREATMENT PLT. [-J Type/Mfg Propert �'/ �� SEWRGE SYSTEM ❑ Distant, to nearest: Well Foundation J DESTRUCTION C7 / No. & Len th of lines' 7 "' 1f -S Total length/size LEACHING LINE 19 ! Property Line FILTER BED ❑ Distance to nearest: Well Foundation �'�_ l Number SEEPAGE PITS Depth �! Size '� r�—�-_- ,�'I - SUMPS ❑ Distance to nearest:. Well • Property Line DISPOSAL PONDS ❑ } 1P0Q)UC WT-hEl2 t the work will be done in accordance with San Joaquin county I hereby certify that I have prepared this application and tha ordinances, state laws, and rules and regulations_of the San,JDaquin 'Local Health District. which this g, "I certifHome owner or licensed agent's signature certifies- she fmanoerni .as to becomeysubjectthatntohworrkman, compensatperformance of lionwlawsfof California." permit is issued, I shall not employ any person signasusubjecti-toews the orkman'slowing: "I ccompensationrlaws that in the of the work for whit Contractor's hiring or sub-contracting, this permit is issued, I shall employ p The applicant must call for all required insp ons: Complete drawif g on reverse side. ' Date: Signed X Title: TM ENtONLI t Stk 466-6781 Application Accepted Area � __ ❑ r I ❑ Lodi 369-3621 Additional Comments: ' - rr� -" Date ��j'� J ❑ Manteca 823-7104 Pit or Grout Inspection b _`� 3 L Tracy ' 635-6385 Final Inspection by " Date Applicant - Return all copies r+vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95 201 DATE PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y INFO 10/82 500 i EH 13-24 REV. 10/82 l 14-26