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�S w II APPLICATION FOR PERMIT ' SAN JCAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-67$1' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r DATE ISSUEQ —..-. A3 �I (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 cal Health District, Job Address + ,`,. . Subdivision Name Owner's Name r Address Phone Contractor's Name `� License No, Phoned --��7 TYPE OF WELL/PUMP WORK: iI NEW-WELL I Q WELL REPLACEMENT DESTRUCTION U f� PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLQ, PROP. LINE f k� FOUNUATdON AGRICULTURE WELL OTHER WELL IA om - PITS/SUMPS,+ t „�+ ,fkr INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ;Open Bottom Manteca Dia. of Well Excavation U Domestic/Private Gravel Pack Tracy Dia, of Well Casing Public M Other Delta V Irrigation �� Type of Casing Approx. [] Eastern Cathodic Protection f Depth :+yr Specifications I 'F Geophysical Depth of Grout Seal Type of Grout L7 Other 9s�, Surface Seal Installed by Repair Work Done D Type of Pump H.P. kState Work Done Well Destruction ❑ Well Diameter Sealing,-Material (top 501) j Depth III Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION �{o septic tank or seepage pit permitted if public sewer is ! , available within 200 feet.) Installation will serve: Residence A Commercial 1f Other � Fr Number of living units: Number of bedrooms ': Lot,size J�Ci g o i F1, r i Character of sail to a de th of 3 feet: , a } t p `' �* Water table depth SEPTIC TANK Ci Ty" /Mfg i Capacity ��No. Compartments PKG. TREATMENT PLT. T e/Mf " ❑ Y4?� 9 Capacity Method of Disp s'al SEWAGE SYSTEM DESTRUCTION ❑ Distance to nearest: Well ,, Foundation �_ �.___�Property:Line LEACHING LINE Nab & Length of lines �.� "� H , Y' Total length/size FILTER BED Distance to nearest: Well r Foundation _ 'Ld> Property Line Ag' SEEPA(E-PITS _ Depth f �� Size 3 �i -I Number 1 /p SUMPS-�r a0 - DisFtance to nearest: Well Foundat' on f�_� Property Line DISPOSAL PONOS ' �(f a 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 notFemploy any person in such manner as to become subject to workman compensation laws of California." E Contractor's hi ing or sub-contracting signature certifies the:,�folIowing: "I certify that in the performance of the work for which this permit is issued, I shalh employ person subject to warkman's comp e ation laws of California." The applic 11 f akll r red s ect- n=. Comple1 dry Ing on reverse side. V �1--, Signed �y� �- - i Date: F R DEP TMENT USE ONLY Application Accepted by. Area — — [V Stk 466-67$1 Additional Comments: Lodi 1 369-3621 Pit or Grout Inspection Date /'/�`� Manteca 823-7104 Final Inspection by Date //-743 L Tracy 835-6385 Applicant - Return all copies, Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , -. ..FEE,: ABASE AMOUNT.-DUE , _ ,AMOUNT_REMITTED._ -RECEhVED BY DATE PERMIT NO. INFO .R EH 13-24 REV. 10/82 I� 14-26 10/82 500 � .. 4 fi