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1 ADPL-KATION FOR PERMIT ,.yaV SAN JOAQLiN LOCAL HPALTH DISTRIC .s 1601 E. HAZELTON AVE., STOCKTON, h T NO. t. Telephone (209) 466-6781 AN Af 1 $ 98" ISSUED � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) SAN JOAQUIN S Application is hereby made to the San Joaquin Local Health District for a permiIIrTsu +V�/ O 11 the work herein f described. This application is made in compliance with San Joaquin County Ordinance No. 54� rim for No. 1862 for wel pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �. S Mull r�p it d. Subdivision Name Owner's Name TCLM V i Address �{ C/ S, �1ii„[ �� Phone 3C/ r Contractor's Name h LI,I M il License No. [./ [[ f Phone ('p �►7g32 TYPE OF WELL/PUMP WORK: NEW WELL ! WELL REPLACEMENT'�5 DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z g'1'#P DISPOSAL FLD. PROP. LINE FOJNOATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Privatr Gravel Pack Tracy Dia. of Well Casing +rs ❑ Public f-1 Other Delta P Type of Casing Lj Irrigation Approx. ❑ Eastern al Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout t7 U Other Surface Seal Installed by (' --41 4.1— Repair .1Repair Work Done [j Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') SQA. te4.1 - -7 ----- — — - — -i 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 O 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 U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS D 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 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 a Toy persons subject to workman's compensation laws of California." The applicant c 11 r 1 squired inspections. Complete drawin on reverse side. 1-7--,P— L'Y' � Signed X Title: Auy Date: OR DEPARTM SE ONLY /&-% Application Accepted by Area 6 Stk 466-67$1 ed%-ir Additional Comments: A ❑ Lodi 369-3621 Pit or Grout Inspectio*to: Environme I Date Manteca 823-7104 I Final Inspection by Date ❑ Tracy 835-6385 i Applicant - Return all copies al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I Y INFO EH 13-24 REV, 10/82 10/82 500A'-- 14-26 00 14-26