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c , APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVZ., STOCKTON, CA a PERMIT N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' �r (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 ul described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump i and the Rules and Regulations of the San Joaquin Local Health District. _ Job Address_J FV0 / Subdivision Name O,} Owner's Name Addresske L d Phone 3 _ 7 LA i Contractor's Name License No. 5P Phone 6 i TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION ❑ i PUMP INSTALLATION SYSTEM REPAIR OTHER -� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ' PROP.. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia. of Well Excavation L} Domestic/Private ❑Gravel Pack Tracy Dia, of Well Casing Public F-1 Other Delta Type of Casing .,JJ-�igat�on � 'Eastern Ap rox. �� (] Specifications Cathodic Protection rW Depth _ Depth of Grout Seal Cm [:)Geophysical Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump' H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residenceavailable within 200 feet.)- x Commercial Other - Number of living units: Number of•bedrooms �-2, Lot 'size ygG�G l Character of soil'to a depth of 3 feet: �'pL� Def _ �- Water table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments..- J PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM �3—�1 Distance to nearest: Well- Foundation !Property Line. _n DESTRUCTION �! �+ LEACHING LINE No. & Length of lines / ��Q �.� Total length/sizeIL - Q FILTER BED IM Distance to nearest-. Well 'yyJ:I�Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS L— Distance to nearest: Well, Foundation Property Line y DISPOSAL PONDS 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 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 workmant compensation laws of Californ'ia." Contractor's h' ' or sub-contracting si ure certifies the following: "I certify that in the performance of the work for-which this permit is issued, I shall employ pe s subject to workman's compensation laws of California." The applica 1 far 1 r quir insp tions. Comple dr on reverse side. Signed X Title: __l�/C � _ (]ate: f7a—a �O D P RTMEN SE ONLY T Application Accepted b Area E] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by $Date Manteca 823-7104 Final inspection by �-°�-�� Date Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE SASE b AM N7 DUE AMOUNT REMITTED . , RECEIVED BY. *DATE., PERMIT NO. — INFO - . . EH 13-24 REV. 10/82 + *-; 10/82 500 ` 14-26