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APPLiCATION FOR PEP11,1T SAN JOAQU;" LOC4L. nEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM 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 and Regguulationsf the San Joaquin L cal Health District. t Job Address M } S. � & A Subdivision-Name J Owner's Name L% A-4- Address , !64 15 , Phone �cC y , Contractor's Name ,� W_ 1..�.��y1P License No, 6 O Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMDESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER + DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INIENUED USE TYPEtOF WELL f� PROBLEM AREA—, "� f CONSTRUCTION SPECIFICATIONS • ❑ Indugtri•a•1•,-----•-•---•--•••-�Open-8ottom�-LDManteca-�w�^�•�'-TDia:•-of-Well--Excavation^~� �'^- p Dome�tic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing y ] Publ �is Other Delta.! ❑ Type of Casing Irrigation "lApprox. ❑ Eastern Specifications Cathodic Protection +Depth ❑ i- F Depth of Grout Seal Geo sical 444 17P Y Type of Grout ❑1Othei Surface Seal Installedd by r Repair Work Done Type of Pump; _ H.P., State Work Done C-�1• V Well Destruction ❑ kWell Diameter Sea Ting Material (top 50') _ 9 jDepth FilIe ,.-Material (Below 50') TYPE OF!S-ISWORK:1 NEW INSTALLATION ElREPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 1 -10 available within 200 feet.) I f1 Installation will ser ! Residence Commercial _ Other Number of living units,. Number of bedrooms Lot size Chara�Ger of soil to a2depfh of 3 feet: Water table depth j SEPTIC TANK. U --Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg,a Capacity Method of Disposal SEWAGE SY.ST�EM ❑ Di-stance to nearest:- Well Foundation Property Line l DESTRUCTION LEACHING.LINE Lj"•'•"No". -& Lerlgtth-sf-1ines Total length/size FILTER BED- ❑ Distance:to nearest: Well Foundation Property Line -� SEEPAGEIPITS Depth �- Size Number SUMPS r ❑ Distance to nearest: Well ! ;mFoun,dation PPoperty Line DISPOSAL PONDS ❑I ' { # i t i I hereby-certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance's, state laws, and rules and regulations of the San Joaquin Local Health District. Home ow�lei-o licensed agent's signature certifies the following: "I certify that in the performance of the work for which this 4 permit a�s"i s ed, I shall not employ any person in such manner as to become subject to workman compensation laws of California." Contracitor' iring or sub ontractin signature certifies the following: "I certify that in the performance of the work for which !, this peSr`m . i issued, I 11 em to person subject to workman's compensation laws of California." The app-i'ca lus�t./c 11 flr 11' ui e in ections. Complete dr ng on r siidCe, i Signed ( Title: T� Date:` I I " FOR DEPARTME US E Application Accepted by rea = ❑ Stk 466-67$1 Additional Comments: ❑ Lodi 369-3621 1P Pit or Grout Inspe on by Date I❑ Manteca 823-7104 Final Inspection by T Date / J ❑ Tracy 835-6385 Applica t - Return all copies toy: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 } VFOAE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. 7 I EH 13-24 REV. 10/82 10/82 500 14-26