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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH:DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO?4C9_I J ` Telephone (209) 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 sewage or No. 1862 for well/pump and the RulesandReeulations of the San Joaquin Local Health District. Job Address674 Ti• Wa0embep 4gE Subdivision Name Owner's Name Address ! Phone 2 3 9—2 5 0 0 Contractor's Name � � ' ti �� " 1IJG License No. <9766(90 Phone q aZD�p TYPE OF WELL/PUMP WORK: NEW.'WELL ❑ WELL REPLACEMENT F-1 DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK 2 4 0 0SEWER LINES 5 5 DISPOSAL FLO. 110 0 PROP. LINE1 0 0 1 FOUNDATION AGRICULTURE WELL 4.5001 OTHER WELL N/A PITS/SUMPS 110 0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial ❑ Open Bottom ]Manteca Dia. of Well Excavation 2 2 1r (.Domestic/Private W Gravel Pack ❑ Tracy Dia, of Well Casing 12 rr 17 Public F-10ther Delta Irrigation Approx. Eastern Type of Casing _ S TEE L P Cathodic Protection Depth Specifications ASTM ❑Geophysical Depth of Grout Seal 10 0 1 U Other Type of Grout CEMENT Surface Seal Installed by Sj)a1 Repair Work Done ❑ Type of Pump 1'08 H.P. a5 State Work Done 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 Installation will serve: Residence . available within 200 feet.)_ 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 No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPS F-1, Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ED 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 employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title; elf(C-5 1WZP//CEj(/r Date: e: Z F Application Accepted by A MENT U E ONLYArea ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date 0 Manteca 823-7104 Final Inspection by Date/47 ❑ Tracy 835-6385 k Applicant - Return all copies to: Environ a tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 6 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ti EH 13-24 R6V. 10/82 10/82 500 y 14-26