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i Rr; i APPLICATION FOR PERMIT iT� 1 SAN JOAQUIN LOCAL HEALTH DISTRICT' U1601 E. HAZELTON AVE.,ISTOCKTON, CA PERMIT NO. Telephone (209) 465-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6 -SAN J0AQUIN LOCAL (complete in Triplicate) Ap THS h rely a e�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. JobAddresses e Subdivision Name Owner's Name �L !i1 (r .T. Address d Phone ff l-35sr Phone - O 3 711_Z3 Contractor's Name Fuviance.DrillersDrilling Col'pense No. — TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER Lf DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �FOUNOATION ,- AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I J Industrial U Open-Bottom []Manteca Dia. of Well Excavation U Domestic/Private ❑Gravel Pack [�Tracy Dia. of Well Casing ❑ Public CjOther ❑ Delta Type of Casing Irrigation Approx. ❑Eastern Specifications { ❑Cathodic Protection Depth v f Depth of Grout Seal 4 Geophysical ' ( Type of Grout �. f ❑Other3 i Surface Seal Installed by Type of PumpH.P.![�► State Work Done Repair Work Done ❑ Typ s F il, ., `— + Well Destruction U Well Diameter Sealing Material.(top-50�) �- Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDIT.ION ❑ (No septic,'tan`k or!'seepage+pit permitted if public sewer is s r 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: f _ Water table depth SEPTIC TANK F-1Type/Mfg f Capacity No. Compartments ' Method of Disposal ' PKG. TREATMENT PLT. ❑ Type/Mfg Capacity - SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ' LEACHING LINE ❑ No. & Length of lines ~Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line lSEEPAGE PITS [ j Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS- ❑ I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,sstate 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 Californiathe work far which California." Contractor's hiring or sub-contracting signature certifies the following: "I'dertify that in the performance of kthis permit is issue I sh employ persons subject to workman's compensation laws of California." GG The appli est 11 or 1 required inspections. Complete drawing on reverse side. pate: Signed X Title: F DEPARTMENT Uk ONLY 3 A O S Stk 466-6781 { Applicati n cepted by Lodi 369-3521 Additional Comments: ❑ Manteca 823-7104 Pit or Grout Inspection by_ Date Date � Tracy 835-6385 Final Inspection by Applicant.- Return all copies to: Environmental Health P rmit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO.- � iNF0 10/82 500 EH 13-24 REV. 10/82 14-26 5