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APPLICATION FOP, PERMT SAN JOAQUi'; LOCAL HEALT :DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. � S.S 7 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. �- 'omplete in Triplicate) Application is hereby made to the San Joaquin Local Health 'District for a permit to construct and/or install the work herein E described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and theRule nd Reg``ulatio o thyye��San aquincal /Health Dista f Job Address •� IIC �/,� /f��/lnw. L� O} 9iinlamc�� 2 CJ37 Owner's Name ��,� ��,/r,�g QQcryi�tae ddress Phone � r�[ r'd J Contractor's Name �iqN&/LD /� }icense No. 73/f Phone W TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT E] DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U v 1 { DISTANCE TO NEAREST: SEPTIC TANK lJ Q U f¢ SEWER LINES /'} �{ DISPOSAL FLD,/0&_4_ PROP. LINE 1. FOUNDATION f AGRICULTURE WELL OTHER WELL PITS/SUMPS .--� INTENDED USE TYPE OF WELL PROBLEM ARkA CONSTRUCTION SPECIFICATIONS eJ k !L) Industrial Open[Bottom ❑ Mante Dia. of Well Excavation LJ Domestic/Private Gravel Pack' ❑ Tra Dia. of Well Casing / Y_ - PublicOther L D to Irri ativn Type of Casing !�� QLl» g ,7Q�J Approx. astern s Cathodic Protection Depth Specifications _- I Depth of Grout Seal - 11 GeophysicalI Type ofGrout Other P Surface Seal Installed by _�(,(�.�/�/1 'Repair Work Done ❑ Type of Pump H.P. State Work Done 1 s. Well Destruction U Well Diameter' Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units; (.Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L] Type/Mfg Capacity Method of Disposal ry SEWAGE SYSTEM Distance'to nearest: Well Foundation Property Line r DESTRUCTION 0 1 LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance:.to nearest: Well Foundation Property Line P SEEPAGE PITS ❑ Depth [ Size Number SUMPS LI Oistancelto nearest: Well Foundation Property Line DISPOSAL PONDS 0 I - I hereby certify that I have prepat red 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, F Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work-for which this ' 4 permit is issued, I shall not employ any perso in such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub-contr cting si a e certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall play p a subject to workman's compensation laws of California." The applican call r requir d spections. Complete drawing on reverse side. Signed X i Title: pE Date: �1 FOR DEPARTMENT USE ONLY Application Accepted by77L Area 5tk 466-6781 Additional Comments: 11. Lodi 369-3621 fl I Flu Pit or Grout Inspection Date Manteca 823-7104 1 Final Inspection by t DateQ,"�\ Tracy 835-6385 OAS.-- Applicant te`Applicant - Return all copies to: Environmental H th Permit/Services 1601 E. Hazelton Ave., P.D. Bax 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY XDATE PERMIT.NO. INFO 3 5S I EH 13-24 REV. 10/82 10/82 500 14-26 d