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ft, .✓ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1661 E. HA7ELTON AVE., STOCKTCN, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT NO. DATE ISSUED 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 307 Ng. Union Road Subdivision Name Artl= Salmn Owner's Name City of 1Tariteca Address 1071 W. Center Street Phone Q— Contractor's Name Calwater Drilling CO. License No. 434218 Phone Z09 -66Z -/9J TYPE OF WELL/PUMP WORK: NEW WELL DISTANCE TO NEAREST PUMP INSTALLATION SEPTIC TANK FOUNDATION ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ❑ SYSTEM REPAIR ❑ OTHER [T Test Hole _ SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ❑ Industrial U Open Bottom M Manteca ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy P bl' CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation _ Dia. of Well Casing 41 ❑ u is [2Q Other_UeSt HoleDelta Type of Casing Ll Irrigation _3_50 ._ Approx.] Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal ❑ Geophysical (If test is satisfactory City Type of Grout LZ Other Test Hole will apply for Pcablic Well) Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ 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 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG, TREATMENT PLT. ❑ Type/Mfg SEWAGE SYSTEM o Distance to nearest: Well DESTRUCTION Other Lot size Water table depth Capacity No. Compartments _ Capacity Method of Disposal Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS LI Depth Size Number SUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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 workmant compensation laws of California." Contractor's hiring or sub-cAntrjacting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I mploy persons subject to workman's compensation laws of California." The applicant st r 1 1 "tions. Complete drawing on reverse side. Signed X Title: DirectorDate: FD PARTMENT USE ONLY Application Accepted by + Area—13 ❑ Stk 466-6781 Additional Comments: [ Lodi 369-3621 Pit or Grout Inspection b Date Manteca 823-7104 Final Inspection by Date "' d ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rINFO E SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT ND. �n �"" f fy} 1 $ S —1 € EH 13-24 REV. 10/82 10/82 500 14-26