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APPLICATION FOR ?&OMIT SAN JOAQUIN LOCAL HEALT+i DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED - l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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 Regulations of the San Joaquin Local Health:District. f Job Address Kku;y r Subdivision Name . Owner's Name 6 b 15 �. 1� AC _ Address Phone Contractor's Name icense No. Phone a TYPE OF WELL/PUMP 14ORK: NEW WELL WELL REPLACEMEN DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR_ OTHER lD a ..'RISPOSAL.FLD. PROP. LINE DISTANCE TONEAREST.__SEPTIC �TANK SEWER�LINES=-� _ s�__. ��----� FOUNDATION S AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial U Open % ttom ❑ Manteca Dia. of Well Excavation Domestic/Private Gravel Pack . - -� Tracy�... Dia .of Well Caring _ �0 - _ � ..� ._ _.- .. . . -_ Public Cj Other {El Delta Type of Casing V Irrigation Approx, Eastern Specifications Cathodic Protection Depth Depth of Grout seal L7 Geophysical Type of Grout Other r Surface Seal Installed by LJ 44 State Work Done Repair Work Done 0 Type of Pump 4 H.P.ti Well Destruction ❑ Well. Diameter I Sealing Material (top 50') Oepthl Filler Material (Below 501) : NEW INSTALLATION ❑P. REREPAIR/ADDITIONF (No'septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK } available within 200 feet.) Installation will serve: Residence Commercial _ Other �a Number` of 6edrao_i Lot sizeo Number of living units: Water table depth Character of soil to a depth of ,3 feet: b � D ti-.• Capacity = '{ ' No. Compartments SEPTIC TANK F-1Type/Mfgl _ s ~+ ; PKC. TREATMENT PLT. � Type/Mfg Capacity -. Method of Disposal SEWAGE SYSTEM Distance, o nearest:-rWell Foundation Property Line DESTRUCTION f LEACHING LINE) No. & Length of lines _�=,�i.� "'Total length/size FILTER BED Distance to nearest:' Well Foundation Property Line SEEPAGE PITS Depth_� Size Number Distance to nearest:, Well Foundat'ion _� Property Line �__�` SUMPS L_I r DISPOSAL PONDS ❑ 1} I hereby certify that I have prepared this,15pplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rulesiand regulations of the San�dOaquin Local Health District. Home owner or licensed agent's signature certifies the fol 1;6, ng: "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 workman'; 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 thi rms�it is issued, shall e ploy persons subject to workman's compensation laws of California." The applican c 1 or Is" ed spectio�r's`Complete dr ing on r verse si Signe _ Titlee Date: OR E ENT USE ONLY �SC1 Stk 456-67$1 Application Accepted by ems JL �] Lodi 369-3621 Additional Comments:. Date Manteca 823-7104 Pit or Grout Inspection by _ Tracy 835-5385 Final Inspection by ti " - Dated ❑ Applicant - Return all copies to: Environmental Health�Pe�r�mit/Serv.ices 1601 E. Hazelton Ave.., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT .,DUE - AMOUNT REMITTED RECEIVED_ 8Y GATE PERMIT N06 y INFO e f-' X 10/82 500 EH 13-24 REV. 10/82 fin( s` C�. C� TZ_,]S 14-26 {� �i s