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01) APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT NO. a ! — 1310 DATE ISSUED %D - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application' -is hereby made to the San'Joaquin L'6ca1 Health District for a permit to construct and/or install the work herein No. 1862 for-well/pump described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or and the Rules and R lations.of thQ San Joaquin .Loca Health District. Job Address .7 !,Y/R ,VY131C�G Subdiyision.Name Owner's Nam �./yK/ �a - f CQ Phone 5g�d/dress Contractor's Name OQ �S OaT� T/�c rise No, .Iiia 746V41 Phone WELL REPLACEMENT DESTRUCTION ��( A3� JV an/ffile t' T TYPE OF WELL/PUMP WORK: NEW WELL PUMP INSTALLATION -� SYSTEM REPAIR OTHER DISTANCE TO NEAR£ST:,SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PTTS/SUMPS 3 Ar re INTENDED USE' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation F-1 Domestic/Private [] Gravel Pack ❑ Tracy Dia. of Well Casing Public Other Delta Type of Casing Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout seal U Geophysical Type of Grout Other Surface Seal Installed by r 0 Repair Work Done E] Type of Pump H.P. State Work Done d— C om+ L#6wiCA Well Destruction xi Well Diameter 0 Sealing Material (top 50') 020 ANB' — Depth 0 Filler Material (Below 50') 4 i ii D= TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION U (No septic tank or seepage pitpermitted ifpublic fsewe) iavailable within 200s Installation will serve: Residence _ Commercial _ Other.` Number of living units: Number of bedrooms . Lot size Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK Type/Mfg PKG. TREATMENT PLT. Type/Mfg SEWAGE SYSTEM Distance to nearest: Well DESTRUCTION LEACHING LINE FILTER BED u No. & Length of lines _ Distance to nearest: Well a Capacity No. Compartments _ Capacity Method of Disposal Foundation Property.Line ~ Total length/size Foundation Property Line SEEPAGE PITS F-1Depth Size Number SUMPS 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 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 workman5 compensation laws of California." Contractor's hiring or sub-contracting,si.gnature 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 applicanust cal for 1 required.ins ections. Complete bra i g on nnlreverse side. Title: GO�IT�' - ?L? Date: Signed X FOR ARTMENT USE A ea Stk 466-6781 l� _�! u (A a Application Accepted by r -, Q Lodi 369-3621 � - Additional Comments: ' - Pit or Grout Inspection by Date � Manteca 823-1104 Date �� ❑ Tracy 835-6385 Final Inspection by f CA 45201 Applicant - Return all copies to; Environmen�1�mt/Services 1601-E, HazeTtom Ave. P.O. Box 2009, Stk., k =�BAS AMOUNT DUE '` AMOUNT REMITTED'"M, RECEIVED BY DATE PERMIT N0. , 1� 10/82 500 EH 13-24 "REV. 10/82 14-26