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;ty � _ APPLICATION FOR PERMIT SEP 1 1333 SAN J0.4QLi'I LOCAL HEALTH DISTRICT r �j f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, lQ-/ .P,?A J'w L ; AL Telephone (209) 466-6781 M � � ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED J'�. (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 Regulations of the San Joaquin Local Health District. } Job Address 1 q0 1_t) 5T . Subdivision Name Owner's Name7WW4ft Address `J ' , j aAi-) Phone Contractor's Name { License No. Phone -v TYPE OF WELL/PUMP WORK: NEW WELL �] ELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ] FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i J industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation mestic/Private ❑Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑10ther ❑ Delta Type of Casing F71 Irrigation Approx. [] Eastern ❑ Cathodic Protection Depth Specifications Depth of Grout Seal 17 Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Dane F—r Type of Pump ti,-P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') Q\ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D (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. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑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 bf t-hB'San Joaquin•Focal--Hea4th-District-, Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whic hthis permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California." Contractor's hirin or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is i ued, I shall employ persons subject to workman's compensation laws of California." The applicant st call f 11 eq it inspect' Complete drawing on r ver a gide. Signed X iJVtIe: Date: (� Application Accepted by FOR Area LJ -�O E] Stk 466-fi781 ER SE ONLY= 1 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ,Manteca 823-7104 Final Inspection by Date 41.1, ❑ Tracy 835-6385 Applicant - Return all copie nvironmental Health Permit/Services 1601 E. Hazelt n Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26