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S r APPLICATION FOR PERMIT" SAN JOAQUIN`LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED ' PERMIT EXPIRES 1 YEAR FROMyDATE ISSUED 4 (Complete in Triplicate) l the rein Application is hereby,madeon'to ithe San iJoaquin iLocal wDithlSan th DJoaquin County istrict for a pO dinanermit ceCNo. 549tfor dsewage sorlNo. 1862rfor ewell/PUMP described. This pp " a and the Rules and Regulations of thelSah Joaquin Local Health District. 304 Address r 3.1 EI'�w ` q T 1-J10n11A6� Subdivision Name S # . Phone' Owner's Name d[�N eddress Phone License No. y3 �� (1 'Contractor's Name lM� VV• TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ _ .`"t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E] DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WE L -PROBLEMAREA" CONSTRUCTION SPECIFICATIONS c". Dia. of Well Excavation j� IndustriDia. of Well Casing al' ❑Open Bottom [Manteca ❑ Domestic/Private�y _Gravel Pack Tracy ❑ Public Other ❑ DeltY a te„ �� y Type_o f,Casing - ""'❑ .� ❑ Eastern '�F-`U'Irrigation Approx. , Specifications 3.t u ❑Cathodic Protection Depth J''-,Ob pth of Grout Seal ,. Geophysical ,,,�•�,�„�,,,,�- „,.-,Y.-,�.,-.-,.,..- ._TYPE-of,Grout�. —� _ ❑Other _ ` Surface--Seal Installed by_� (E' State Work Done, `- _ ik Repair WoDone �] Type of Pump i' H P. sealing Material (top 50') \ el Destructions F-1 Well Diameter — i Depth-.--4 --” """- '"'Fil ler Material (Below 50') f it ermitted`if public sewer is TYPE OF+SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit within,200`feet.) Installation will serve: Residence _ Commercial _ Other Number of bedrooms Lot size Number of living units: Water table depth Character of soil to a depth of 3 feet: pa�o s+ _ UU No. Compartments SEPTIC TANK [Vf Type/Mfg CCA S _ ; - _._Capacity /� M ' _ Capacity Method of Disposal PKG. TREATMENT PLT. Type/Mfg property Line SEWAGE SYSTEM Distance to nearest: Wel'1 Foundations " DESTRUCTION 'I , p� ._. No. & Length of lines Notal length/size LEACHING LINE 9 i Property Line f FILTER BED�� ❑ Distance to nearest: Well Foundation SEEPAGE PITS E5 ,,,,..Depth Size Number Foundation Property Line "SUMP LJ Dista ce�to_nearest Well s DISPOSAL"PONDS_ �� D � I hereby certify that I have-prepared-this app ion and what theme ork"wi.lJ�be done in accordance with San Joaquin county ordinances' state laws, and rules and regulations• of the San Joaqu.ih Local Hea lth-District. Home owner or licensed agent's signature certifie�he 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 becoine .subject to workman$ compensation laws of Californiaic Contractor's hiring or sub-contracting signature certifies the n'sfoilcoipensa certify that in the performance of thework for which this permit is issued, I shall emp by persons subject to workman's compensation laws•of California." I The applic call f all r aired inspections. Complete drawing o�verse side. „may Date: �0s, Title: �--�'tt��++ � signed X - 4^ R DEPARTMENT USE ONLY ` ❑ Stk 466-67.81 GJ /__ D Application Accepted by, -Area ❑ Lodi 369-3621''"'-_� Additional Comments: Date C50anteca 823-7104 ` f t'or Grout Inspection by Tracy 835-6385 1 Final Inspection by Date 7 C i Applicant - Return all copies t�: Environmenta ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 DATE PERMIT NO. FEE BASE AMOUNT, DUE AMOUNT REMITTED RECEIVED BY _ INFO s 16/82 500 EH 13-24 REV, 10/82 14-26 i _ x