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jf APPLICATION FOR PERMIT �q 7 SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT N0. 0_ 3 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 DATE ISSUED IcN"a'- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j f permit to construct and/or install the work herein Application is hereby made to the San Joaquin Local Health District fora p , described. This application is madelin compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump pump and the Rules and Re ulations of the,San Joaquin Local Health District. rV\ ti" Subdivision Name Z Job Address c � 'C Phone Owner's Name U 'k Address Phone --�— Contractors Name License No. TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR 0 PROP. LINE DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK 1_�.,_ SEWER LINES _ OTHER WELL PITS/SUMPS FOUNDATION !.1 AGRICULTURE WELL LEM AREA �� —�—- CONSTRUCTION SPECIFICATIONS _ • `, Ay�✓ INTENDED USE TYPES ff WELL PROBDia. of Well Excavation V" Industrial U Open Bottom [}Manteca U Domestic/Private E]Gravel Pack ❑Tracy Dia, of Well Casing ❑ Public ❑Other, ❑Delta Type of Casing Approx. []Eastern Specifications ❑ Irrigation Depth ❑Cathodic Protection Depth of Grout Seal El Type of Grout E Surface Seal Installed by ❑Other YP �. Repair Work Gone ❑ Type of Pump H.P. State Work Done Sealing Material (top'SD'). --- J Well Destruction ❑ Well Diameter Filler Material (Below 50') Depth available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L} (No septic tank or seepage pit permitted if public sewer is . le Commercial Other Installation will serve: Residence _ Lot size r Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments � SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG EATMENT''PL.T. F'] Type/Mfg Foundation Property Line SEWAGE SYSTEM Distance to nearest: Well ESTRUCTION Total length/size LEACHING L ❑ No. & Length of lines Property Line ❑ Distance to nearest: Well Foundation _��-- p r FILTER BED a SEEPAGE PITS Depth l Size Number ❑_ Foundation Property Line SUMPS LJ Distance to nearest: Well —� DISPOSAL PONDS ❑ t 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 c1ens the suchfmannernas to become: ysubject ntohworkman�compensatlionaws work lfor of California." permit is issued, i,shall not employ any person � Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whit bject to workman's compensation laws of California. this permit is issued, I shall employ persons su The a0:,�;;��ZRTMENT ns. Complete drawing on reverse side. Date: Y Title: Signe USE ONLY Area _,0_ , Stk 466-6781 Application Accepted by ❑ Lodi 369-3621 Additional Comments:. ate ❑ Tracy Manteca 823-7104 Pit or Grout Inspection by 835-6385 f �� Date ❑ Final Inspection by � alth Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, 5t k., CA Applicant - Return all copies to: Environmental He95201 r DATE PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ��—��3 L�� INFO 4 O 10/82 500 EH 13-24 REV. 10/82 14-26 -