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IRR T APPLICATION F04 PEn'i'iIT � SA11 JOAQUi LOCAL tiE .LTN 3I, ,T 10 1601 E. HRZELTOti AVE., STOCKTON, CK PERh1IT NO. Telephone (209) 466-6781 ! JOAQUIN [-.MAL DATE ISSUED `1—-93 PERMIT EXPIRES_1 YEAR FROM D4TE WALTH DISTRICT (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 Na, 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address QQ Subdivision Name Owner's Name Address Phone Contractor's Name ense No, C-24 :762!46 Phone I TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION L] 1 PUMP INSTALLATION SYSTEM REPAIR OTHER L 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'DISPOSAL'FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing Public [-1 Other F_� Delta Type of Casing V Irrigation Approx. Eastern EJ Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical Type of Grout L Other 0 Surface Seal Installed by t Repair Work Done Type of Pump� t H.P, Q State Work Done �rhP �� Well Destruction U Well Diameter Sealing Material (top 50') , Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Installation will serve: Residence _ Commercial Other r1 Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth ^' SEPTIC TANK L Type/Mfg Capacity No. Compartments V PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundatiof Property Line DESTRUCTION LEACHING LINE L No. & Length of lines ¢ Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS L Depth Size Number SUMPS a Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L 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 workman compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: - Date: 9 �� FORRTMENT USE ONLY Application Accepted by F j�I�j1f�N�� _ Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date 1-1 R Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haz ton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE. AMOUNT REMITTED RECEIVED BYFT PERMIT NO. INFO � g3- 17 EH 13-24' REV, 10/82 10/82 500 14-26