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r APPLICATION FOR PER.MiT SAN JOAQLIN LOCAL, HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. �-— �,b Telephone (2.09) 466-6781 9 DATE ISSUED `�— PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San-Joaqui6 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 and//Re ulationso the an Joaquin Local Health District. V Joh Address [po �< rx (f !/ �R ubdivision Name I `C Owner's Name /V Address l: }"+ �Y�` alc-��. 1• �Phoneg��/old Contractor's Name License No. 1(/ Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS t t INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial [f Open Bottom ' ❑ Manteca Dia, of Well Excavation .Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public Other ❑ Delta Type of Casing X'Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth ❑ iDepth of Grout Seal ❑Geophysical Type of Grout L]Other Surface Seal Installed by 00 Repair Work Done Type of Pump tj� H.P.N , 4.0 State Work Done a tt Well Destruction ❑ Well Diameter sealing Material (top 50') _ Depth . Filler Material (Below 50') 4 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION;❑ (No septic tank or seepage pit permitted if public sewer is 1 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line F 1 DESTRUCTION ❑ I r LEACHING LINE ❑ No. &'Length of lines Total length/size r a f FILTER BED ❑ Distance to nearest: Well Foundation Property Line ji SEEPAGE PITS CI Depth' Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �} f I hereby certify that 1 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 workmans 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 applicant mufor all required inspections. Complete d- ing on reverse side. Signed X 1 Title: Date: qlY CFOR DEPARTMENT USE ONLY ❑ Application Accepted by� � � Area Stk 0.66-6781 Additional Comments: jj ❑ Lodi 369-3621 Pit or Grout Inspection by Date iX ,Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 I Applicant - Return all copies} o: nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f FEE BASE AMOUNT DUE AMOUNT.REMITTED RECEIVED BY DATE PERMIT NO. INFO - N10/82 500 EH 13-24 REV. 10/82 14-26 - '