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APPLICATION FOR PERMIT SAN 30AQUIN LOCAL HEALTH DISTRICT PERMIT N0. � 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 DATE ISSUED i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a (Complete in Triplicate) with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump n is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein � Applicattio lication is made in compliant described. This app and the Rules and Regulations of the San Joaquin Local Health Subdivision Name Phone Job Address Address Phone Owner's Name License No. Contractor's Name DESTRUCT ION NEW,w ELL ❑ WELL REPLACEMENT [� TYPE OF WELL/PUMP WORK: ❑ •OTF(ER ,❑ tr ' SYSTEM REPAIR DISPOSAL FLD. ��PROP. LINE .PUMP INSTALLATION SEWER LINES ��PITS/5UMP5 C TANK WELL DISTANCE TO NOTHER EAREST: SEPTI ��-- AGRICULTURE wELL ^� _4 FOUNDATION y . PROBLEM AREA CONSTRUCTION SPECIFICATIONS k, INTEN� OED USE TYPEEOOF WEtL -—�- Dia. of Well Excavation en Bottom []Manteca Op Industrial I t Dia. of Well Casing r •-Y �- �� '�� Gravel Pack E Tracy T y Domestic/Private - - ❑Delta R Type of Casing public ; t s " 4 � Approx. ['}Ea_stern Specifications LJ Irrigation Depth Depth of Grout Seal - E]Cathodic-Protection Type of Grout ; LJ Geophysicair Surface Seal Installed by Other 5 Repair Work Done [j Type of Pump �__.�- State,Work-Done �fD' I Well- Diameter!_,� Sealing Material {top f Weil Destruction L} Filler Material (Below 50'} V" ,.•~•-'Depth No septic tank or. seepage pit permitted if public sewer is REPAIR/ADDITION ( available within 200 feet.) TYPE OF SEPTIC 'WORK: NEW INSTAL,ATION U y C- Commercial Other Installation will serve: Residence — o Lot size Nuinber`of living units: t Number,o`f bedrooms Water table depth e Character of Soil to a depth.of 3 feet: Capacity u - No'. �Gompartments SEPTIC TANK ' Type/Mfg �� Method of�Disposal Capacity'-. �IMry TYpe/•Mfg-^s• Property.Line F_�Y_ Sep is ATan&pLT .-" Foundation Destruction Distance to nearest: Well '" i Total length/size s T LEACHING LINE No. & Length of lines Property Line Distance to neare ��_ st: Well Foundation FILTER BED Depth Size Plumber E SEEPAGE PITS y .. ; Foundation - -) prflperty Line k SUMPS y_J Distance to nearest: Well. . x -y F DISPOSAL PONDS k hereb certify that I have prepared this application and that the work will be done in accordance with San Joaquin county I y ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature cersontin suchfmannerng: 111 certif�-that as to become.'subjectntohworkman 5 compensathonwlawtfef California."i { permit:is issued, I shall not employ any pthe Contractor's hiring or sub-contracting ersonsusubject�toeworkman�slcompensationrlaws ofaCaliforniat in the Erformance of the work for whit this permit is issue i shall p1oY P - e apPlic u t c 1 r al equi d ections. Complete awing on' Date: d� � 'Title: _- • S�9 �r FOR TMENT USE ONLY Area 5tk 4fi6-6781 r , Application Accepted by �f 7 `" � "`r' odi 364-3621 Additional Comments: Date Manteca 823-7104 Pit or Grout Inspection b Tracy 83576385 ISe DateFinal inspection by �� CA95201 Applicant-Return ahl copieso:--Enviro ental`Health"-Permitvices 1601 E, azeltan Ave., P.O. Box 2004, Stk., DATE PERMIT NO, AMOUNT REMITTED RECEIVED 8Y FEE BASE AMOUNT, .DUE ; - INFO' .. -S� gZ 70 0 10/82 500 EH 13-24 REV. 10/82 14-26