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Seer 2 0, lw3 j 1 APPLICATION FOR,PERMiT SAN 30AQUi N LOCAL HEALTH :,!STRICT - SEP q ej 2 � 1601 E. HAZEL.TON AVE., STOCKTON, CA PERMIT NO. 0� l V 13 J 1 Telephone (209) 466-6781 GATE ISSUED �q PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ``SAN `rOl�QUN MAL (Complete in Triplicate) HEALTH DISTRICT , 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 w .S �j' Subdivision Name 77. Owner's Name dress Q `-S/lGrl. Phone Contractor's Name i?uryiance DrillingDrill ers. Corp. License No. 3 �L(iPhone A TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER LJ DISTANCE TO NEAREST: "SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE, TYPE,O.F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS •Industrial f ' `— (vti} "J '' `' z U�Operi Bottom ` �' � Manteca Dia, of Well Excavation Domestic""/Private L-i [] Gravel Pack Tracy Dia, of Well Casing _ E (]'Public Other Delta �p! Type of Casing Irrigation N .Approx. Eastern Cathodic Protection t Depth` Specifications l7 Geophysical' '-.J y Depth of Grout Seal uOther Type of Grout Surface Seal Installed by Repair Work Done Type of Pump .;Mp. H.P, 419 State Work'Done Well Destruction U Well Diameter Sealing Material (top 50') j 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 _ 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 x No. Compartments _ PKG. TREATMENT PLT. ❑~ Type/Mfg Capacity T i Methof'_Dispos od al — SEWAGE SYSTEM Distance to•nearest: Well Foundation Property Line" DESTRUCTION _ ._ _ - - ` f LEACHING LINE U No. & Length of lines Total length/size FILTER BED = " Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS L Distance to nearest: Well Foundation Property L"ine- -• } DISPOSAL PONDS I hereby certify that`l"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 workman compensation laws of California." Contractor's hiring or sub-contracting signature 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 applicant must c 101 or ll required inspections. Complete drawing on reverse side. 5igned.X Title: Vt� Date: q—q—�� TMENT E ONLY Application Acce ted by Area _ >�Stk 466-6781 Additional Comments: Lodi- 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 �. Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 . I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 1 EH 13-24 REV. 10/82 10/82 500 14-26 ,