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APPLICATION FOR SAN JOAQLi ,' LOCAL HEALTH DISTRICT �a a 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT N0, PERMIT EXPIRES 3 YEAR FROM DATE ISSUED —� - DATE ISSUED (Complete in Triplicate) Application is hereby made to theiSan Joaquin Local He described. This application is made in compliance with San Joa uin County Ordinance No. ruc Health District fora permit to construct and/or install the work herein and the Rule and Regulations o the San Jo�q alth Job Addres uir Lv a rict. 549 for sewage or No. 1862 for well � L��L] /pump Owner's Name Su Co ntractor'S Na Address e►�" License Na. Phone Phon TYPE e/? `"�^3;� 4,/ OF WELL/PUMP WORK: NE4!WELL / WELL REPLACEMENT .� r r, PUMP INSTALLATION I #� �f:DESTRUCT1oN DISTANCE TO NEAREST: SEPTIC TANK Cg p SYSTEM REPAIR `" 7 OTHER i SEWER LINES C1 DISPOSAL FLD 1 - FOUNDATION AGRICULTURE WELL PROP. LINE gINTENDED USE OTHER WELL PITS/SUMPS ��--- TYPE OF WELL U Open PROBLEM AREA I f,Industrial —�� CONSTRUCTION SPECIFICATIONS ! j+(+ I Domestic/Private Bottom Manteca Dia. of Well Excavation EJ Gravel "Pack Tracy Other L3 Public Dia. of Well Casing V Irrigation CJ 17Del to Type of Casing 0 Cathodic Protection Deprox EJ Eastern Easterni p Specifications EJ Geophysical Depth of Grout Seal T� e ` 3 U Other Type of Grout Repair Work Done TySurface Seal Insta led by Type of Pum H.P, State Work Dane Well Destruction LJ Well Diameter IV Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J NO septic tank or seepage pit permitted if Installation will serve: Residence public sewer is _ Commercial Other available withih 200 feet.) Number of hiving units: Number of bedroomsF Character f'so l,Lto ,a depth of 3 feet: Lot size ; —.--. SEPTIC TANK Water table depth , i Lf� Type/Mfg Capacity No. Compartments ❑ >GType/Mfg Capacity Method of Disposal; , SEWAGE SYSTEM Distance to`nearest: Well DESTRUCTION Foundation Property Line LEACHING LINE ` I U No:`-"&'Lergth of lines Total length/size FILTER BEDF Distance totnearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS L—I Distance to 4 earest: Well Foundation Property Line it"3 DISPOSAL PONDS , I hereby certify. that I have prepared this application and that the work will be done in accordance with San iJoaquin county ordinances, state laws, and rules and 'regulations of the San Joaquin Local Health District. dome owner or licensed agent's signature certifies the following: "I certify that in the performance of the wo k,for which this permit is issued, I shall not employ any person in such manner as to become subject to workman compensation 1t ws of California." Contractor's iring }or sub-contracting signat re certifies the following: "I certify that in the performance of the work for which , this permit s issued, I shall a to erson subject to workman's compensation laws of California." The appli nt ust cl 1 for all q in ections. Complete on reverse side. �'" Signed X L Title: Date: rl��-o"z IhTMEN SE OWLY i Application Accepted Area �� Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or GroutiInspectior by Date Manteca 823-7104 F 1 Final Inspection-by-- _ -.mss/-�= �. .•, 4Tracy...b„835-6385 Applicant - Return all copies to:: n onnientallHeaLth;Permit/Services 1601 .E` Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED INFO BY DATE PERMIT NO. INFO - z -8�7--12 EH 13-24 REV. 10/82 14-2610/82 500