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0. .1 APPLICATION FOR,PERMIT .� SAN JCAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 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 compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules qRtegulatio s of he San Joaquin Loca H lth District. Job Address Su division Name Owner's NanAddress PhoneContractor's N License No. Phone Bf-` TYPE OF WELL/PUMP WORK: NEW WELL -' f .WEL[,�REPLACEMENTf []`} ' DESTRUCTION Lf " PUMP'INSTALLATION SYSTEM -REPAIR -�'" OTHER, l__� DISTANCE TO NEAREST: SEPTIC TANK` SEWER LINES°y,, DISPOSAL FLO. PROP,µ LINE GR FOUNDATION r R �_ AICUCTURE"WELL,,.; OTHER WELL PITS/SUMPS INTENDED USE TY71E1,OF WELL PROBLEM AREA ` CONSTRUCTION SPECIFICATIONS ` ❑ Industrial U Open Bottom Manteca Dia, of Well Excavation ❑ Domestic/Private Gravel Pack Q Tracy cDia. of -Well Casing Public EJ other[]_Delta t irrigation ` Type of Casing �u 9 Approx. 0 EasternS "ecifications Cathodic Protection Deptri r „_ p._ .Depth of Grout.Seal 1-1 Geophysical " F-1Other ; TYp? of Grout Surface Seal' Installed by Repair Work Done [J Type of .Pump A . H.P. '.State Work Done z Well Destruction ❑ Wel I'Diameter w-tSealing Material (tbp 501)• Depths; f Filler Material -(Below ) } 9ti4` " TYPE OF SEPTIC WORK: NEW INSTALL'ATION`S REPAIR%.,ADDITION (No�septit tank or seepage pit permitted if public sewer is c` avb within 200 feet.) Installation will serve:. Residence Commercial er Other 3 q u OZ% Number of living units: Number of drooms f ""# -"" ,Lot size fi AMOUNT DUE Character of soil to to a pth of 3 eet: ater table depth SEPTIC TANK ua' Capacity o. Compartments PKG. TREATMENT PLT, T e/Mf ❑ YP g —'"""" ' Capacity v� Method of Disposal SEWAGE SYSTEM DESTRUCTION Distance to nearest: ❑ Well Foundation �} - t-�-- r Property Line LEACHING LINE U No. & Length of lines Total length/size FILTER --BED Distance to nearest:. 11 Well Foundation Property Line SEEPAGE PITS Depth ' Size F Number SUMPS ❑ Distance to nearest: well �' Foundation Property Line DISPOSAL PONDS ✓ y 1 f 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. I.,'. Home owner or licensed agent's signature certifies the following:""I .certify that in the performance of the workJbr_ which this permit is issued, I shall not employ any person in such manner as to become subject to workmanK compensation lav;''of California." Contractor's hiring or sub -contracting signature certifies the :following: "I certify that-in-the-per-formance•of'the'work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California. The applicantm t call Ual required ins ections. Complete drawing on e r e side. s Signed X Title: _ _ r A Date: OR T USE ONLY Application Accepted by D PART N _ Area L- ` ..�- ;;.�Q-Stk.-_ 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date ❑ Manteca 823-7104 Final Inspection by M — ,jt• -pate= Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 160 E"azelton Ave „ P.O. Box 2009, Stk., CA 95201 FEE INFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. EH 13-24 REV. 10/82 10/82 500 14-26