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APPLICATION FOR PERMIT SAN JOAQ� N LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (204) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (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 sew e or Na, 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. A + — p Job Address4123 E Woodward Manteca Subdivision Name ' 1y/l/i Owner's Name David Lain Address 10 S . Main S-Meet LodiPhone 369-4448 { Contractor's Name Mark Well License No. 371560 - Phone 462-�r�C�7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PJMP,INSTALLATION ❑ SYSTEM REPAIR ❑ + OTHER ❑� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE ° FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ,XJ Open Bottom ❑Manteca Dia. of Well Excavations Lf Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing /Ly++ l~^ ❑ Public ❑Other ❑ Delta Type of CasingI�o � Irrigation Approx. ❑ Eastern Cathodic Protection Depth Specifications Depth of Grout Seal Other ❑Geophysical Type of Grout Surface Seal Installed by Repair Work [lone ❑ Type of Pump H.P. State Work Done rn Well Destruction Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE"OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is EE available within 200 feet.) Installation will serve: Residence _ Commercial _ Other 0 Number of living units: Number of bedrooms Lot size Q^ Character of soil to a depth of 3 feet: Water table depth L+ 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 ❑ i., LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ f Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s A" . I hereby certify that I havepprepared this application and that the work will be done in accordance with San 0o8quin county , ordinances, state laws, and es 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 thework for which this t" permit is issued, I shall not,employ any person in such manner as to become subject to workman t compensation_laws of California." Contractor's hiring or sub-contracting'sighature certifies-the-folIowing:—1-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.- r The applicant m calTfor AQ reire nspec ions. —'Complete-drawing'on reverse side. Date: _ Signed X Titre: 1/22/RC F EPARTMENT USE ONLY �� Application Accepted by Area ❑ Stk 466-6781 — W A Additional Comments: ❑ Lodi 369-3621 ,pto.. Pit or Grout Inspection by Date X Manteca 823-7104 fill Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO EH 13-24 REV. 10/82 10/82 500 14-26 ' t