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1 APPLICATION FOR PER.MiT SAN JOAQUiN LOCAL HEALTH 'uISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. U `"I Telephone (209) 4606781 a } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 compliarce with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address //�'Ar All 41` �wWWII �" by Subdivision Name Owner's Name Address Phone Contractor's Name /Q/y gay y Svc License No. v�y17" 9Phone S.Z-7-5/ 7 � II - TYPE OF WELL/PUMP WORK: N 6 WELL ❑ WELL REPLACEMENT ❑ F-- -- • PUMP INSTALLATION - SYSTEM -REPAIR DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES FOUNDATION �. AGRICULTURE WELL DESTRUCTION. U .A j -OTHER'U' DISPOSAL FLD, PROP. LINE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial — TU-Ope-ntB6ftnm r Man teca"Dia:-of-well E Excavation E U Domestic/Private Gravel Pack Tracy Dia, of Well Casing r Publicl Other Delta i Type,,oi�Casing Lj Irrigation Approx. t t=j.Eastern Foundatior Cathodic Protection Depth units. r Specifications F ------.�- Geophysical _' ;� _.-�� _.-Depth..of_Grout_Seal I U � � Other Character of soil to a depth ofs3 Type of Grout } Water table depth ! Surface Seal Installed by Repair Work Done Type of Pump H. -P. State Work Done Well Destruction Well Well Diameter PKG. TREATMENT Seal-ing Material (top 50') Depth "'J " ' Filler,Material (Below 501) �� Distance TYPE OF SEPTIC WORK: NEW INSTALLkh0N REPAIR/ADDITION ) (No septic tank or seepage pit permitted if public sewer is FILTER BED p� Distance; to nearesf: WeiI - T-- -- _. --- - -- -'- --- --- �---ava.i-lable-wi-thin.200 feet.) - Size Installation will serve: Residence Commercial Other Well Foundatior DISPOSAL PONDS Number of living units. i�Number _,t of bedrooms size Character of soil to a depth ofs3 feet: I Water table depth SEPTIC TANK I E]Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM �� Distance to nearest: Well Foundation Property Line DESTRUCTION t LEACHING LINE U No. & Length of lines I__1001 �. FILTER BED Distance; to nearesf: WeiI Foundation SEEPAGE PITS F -j Depth Size ✓ SUMPS .10_ Distance to nearest: Well Foundatior DISPOSAL PONDS f i Total length/size 1,00 Property Line SUS Number Property Line TO 3 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 JoaquinLocal 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 must all for all required ins�DEPARTM�ENT Complete drawing on reverse side. Signed X Title: Date:OR USE ONLY c Application Accepted by N--� Area [] Stk 465-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection byDate NE Manteca 823-7104 Final,lnspection by Date, 1- 7 = L Tracy 835-6385 Applicant - Return all copies t - +Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE BASE AMOUNT DLE AMOUNT REMITTED INFO EH 13-24 REV. 10/82 14-26 RECEIVED BY DATE PERMIT NO, 10182 500