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APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT - 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM 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 Rules and Regulations of the San Joaquin Local Health District. Job Address Subdivision Name Owner's Name �Vf�i �fir /11BAf Address � f �� ,ut/ / I,/iTQ„�QPhonei�, � Contractor's Name �.�FI�.LLL�' License No. ' /�ri'�i`�`_� 7--- — Phone ; 4,P'1,1a 13 TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT E] DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPEC IFJCAT-IONS- LJ Industrial Ej Open Bottom_ Manteca Dia. .of Well Excavation 'S U Domestic/Private ;Gravel Pack Tracy Dia. of Well Casiig 17 Public Lj'Other ❑ Delta Type of Casing Lj Irrigation Approx. [�] Eastern Cathodic Protection Depth * Specifications FI Depth of Grout:Saal-- 17 Geophysical Other s - Type of Grout Surface Seal Installed by . Repair Work Done Q TypeLdf Pump H.P. State Work Done ' Well Destruction U Well Diameter Sealing Material (tibp 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION §-e- (No septic tank or seepage pit:permitted if public sewer is - .. available within 200 feet.) h' Installation will serve: Residence �( Commercial Other% V Number of living units: Number of bedrooms' _,3 Lot-site Character of soil to a def t. of.3_.feet: SA1liUti L1 Water table depth �j 7 SEPTIC TANK ' ❑ .,Type/Mfg'\ Capacity No. Compartments PKG. TREATMENT PLT. LJ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEA61NG LINE I No, & Length of lines T Total length/size /-"T i / G FILTEBED4% '' Distance to nearest: WellFoundation _ -__- Property Line - SEEPAGE PITS i Depth Size Number SUMPS U Distance'toY nearest: Well Foundation Property Line 01SPOSAL PONDS ❑ .�%L' Y,f s t I hereby certify that I have prepared this application and that the work will he done in accordance with San ,Joaquin county ordinances, state laws, and rues and regulations of the San'Joaquin Local Health District. Home owner or l ZEnsed�a gent's:signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I 'sha11' not &mploy any person in such manner as to become subject to workmans 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 cal ar al r�e�q�uired inspections. Complete drawing on reverse side. } Signed X �/} ' Title Date: J L FOR DEPARTMENT USE ONLY �[ Application Accepted byA �J''�-�� Area (�J [] Stk 466-6781 Additional Comments: ��- Lodi 369-3621 Pit or Grout Inspection by Date > Manteca 823-7104 Final inspection by k Date lb!!fk-* ,�3 >✓y1 L Tracy 835-6385 Applicant - Return all copies to- Environmental Health Permit/Services 1601 F. Hazelton A1vee., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED.BY. DATE PERMIT N0. INFOAl I!-,"�83 3f 1 -� 10/82 500 _. EH 13-24 REV. 10182 Ll 14-26 _^fie