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v APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT " y1 1601 E. HAZELTON AVE., STOCKTON, CA PER N0. Telephone (209) 466--5781 DATE ISSUED . PERMIT EXPIRES 1 YEAR FROM 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 described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules &ulwions of t&Joag� Local Health District. Job Addrss O S hdivisia Nam]� G Phone Owner"s Name Addre s�. Phone Contractor's Name icense No. TYPE OF WELL/PUMP WORK: �. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 'OTHER PUMP INSTALLATION ❑ ..SYSTEM REPAIR ,❑ YI 19" U '` i �y SEWER-LY INS + F DISPOSAL PLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK -- FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,~„ # ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy_,f Dia, of Well Casing U a w . _ - .....,,..�,- ..1.I� -��:....._. � 1-1Publi•c., ❑Otherl 4❑ Del to Type of Casing _ Irrigat-ion. Approx. ❑Eastern Specifications < E ❑Cathodic Protection Depth t Depth of Grout Seal ❑Geophysical U.• ` ` 4 Type of Grout ❑Other r ,i .. t " - � Surface Seal Installed by i ► F Repair Work Done ❑ Type of'.Pump H.P. State Work Done { � t, Wel1'"Destruction ❑ Well Diameter' Sealing Material (top 50') - e Depth Filler Material (Below 50') r.. OQ ermittd if sewer TYPE OF SEPTIC WORK. NEW INSTALLATION D, REPAIR/ADDITION ❑ (No septic tank r seepage_ ;a_va lableewit_hinu200cfeet.) is Installation will serve: R ideice - Commercial OtherL3U , i Number of bed roams �]� \ Lot size Number of living units: Water table depth Character of soil to a depth of'3 feet; < i f- Capacity, No. Compartments s SEPTIC TANK ❑ Type/Mfg , Capacity Method of Disposal PKG. -TREATMENT PLT. ❑ Type/Mfg i t `SEWAGE SYSTEM Q Distancejo nearest: Well Foundation, Property Line n DESTRUCTION -iQ s {� ❑ No. & Length of lines Total length/size FILTER BED Distance4to nearest: Weli� Foundation Property L' e ( Size Number, SEEPAGE PITS F-1Depth -- SUMPS ❑ Distance'to nearest: :Well Foundation Property Line DISPOSAL PONDS ❑ { f w that the work will be-done in accordance with'Sen Joaquin.county this application and ) d t t . I hereby certify that 1 have prepare PP ordinances, statejlaws, and rules and regulations of the San Joaquin Local Health Dzsthe,p. that I Home owner or'licen�ed agent's signature.cerson1en suchmanner' to become subjectntohw6rkman'scompensati�onwlaws fof California." permit is issued, I_shall'not empl-dy any-_p T Contractorv§-,hiring-or sub-contractcertifies the following: "I certify that in the performance of the Bork for which �Sperml f-is issued, 1 s 11 employ persors_subjectto.workman's--compensation_l,aws. of California.Tn must 1 o all eq ed"in pections. Complete wing-e? - ATitle0ateS - ,v"7FORt'EPAMENT USE ONLY' jr 1 �Stk 66-6781. i Application'Accepted.by 'f"e Area �_- ❑ Lodi 369-3621', Additional Comments: r ' Date ; ❑ Manteca 823=7104 Pit'or Grout Inspect' n ., Tracy 835-6385? i `Final Inspection by Date fr ,. pi o:• Heal i601 E. Hazelton Ave., P.O. Box 2009, Stk.,'CA 95201 Applicant - Return all coEnvironmental r RECEIVED BY DATE PERMIT NO. FEE BASE NT DUE 'AMOUNT REMITTEQ_ ( { r INFO ` 10/82 500 EH 13-24 REV, 10/821 IA c .-r z n f . 4-26 , C.-' +`�