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A APPLICATION FOR PERMIT 1 � L SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.. Telephone (209) 466-6781 DATE ISSUED " # PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,G 6,c e r' soA�Q�4� � (Complete in Triplicate) Applicatibhf- h ►'e`by 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 Addresubdivision Name Owner's Name Add ss Phone 6G� Contractor's Name (' /i'_t�f / ° 4. � Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ -7 I PUMP INSTALLATION C] SYSTEM REPAIR OTHER E] 63 Z ! ?3 Z DISTANCE TO NEAREST: SEPTIC TANK �� ) SEWER LINES DISPOSAL FLO. II PROP._LINE _ - - -� FOUNDATION AGRICULTURE WELL DTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIDNS f/ Industrial ❑Open Bottom 2;:+lanteca Dia. of Well Excavationb "Domestic/Private ravel Pack []Tracy Dia. of Well Casing & ❑ Public ❑Other ❑Delta Type of Casing AA1,11 ❑ Irrigation JJZ - Approx. ❑Eastern i Specifications Z Cathodic "Protection Depth F-1 $ Depth of Grout Seal 17 Geophysical Type of Grout ! Other �. .��'Sui^face Seal Installed by "° - j- '""'""""'^State Work Done Repair Work Done ❑ Type of Pump H•P• - ' Well Destruction ❑ Well Diameter Sealing Material (top 501) t F Depth - Filler Material (Below 50') Q i O : INSTALLATION ❑ REPAIR/ADDITION (No'septic�tank or seepage pit perrtiittedYif pub-itc seWwr TYPE SEPTIC'WORKNEW INSTA T available within 200 feet.) k Installation will serve: Residence _ Commercial Other , Number of living units: Number of bedrooms Lot size LA Character of soil to a depth cf 3 feet: Water table depth [ SEPTIC TANK ❑ Type/Mfg ) Capacity r No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg = Capacity = i Method of Disposal '` e Distance to nearest: Well Foundation i Property Line LEACHING LINE 71 No. & Length of lines X Total length/size ✓ Pro arty Line FILTER BED [3 Distance to nearest: Well Foundation P SEEPAGE PITS ❑ Depth Size Number SUMPS LJ 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 k compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify thatbin the performance of the work for which this permit is tissued I shall employ persons subject to workman's compensation laws of California." The applican u c fora re uired inspections. Complete dra 9 on re rse si r — Signed X Title: 4Date .-4-- VRT.MENT USE 0 Y �r�� Application Accepted byArea �� ❑ Stk 466-6781 Additional Comments: d -- v 0 ,crv' k.tr_ 1 ❑ Lodi 369-3621. Pit or Grout Inspection by Oat e Manteca 823-7144 i Final Inspection by Tracy 835-6385 Date � ^— Applicant - Return all copies to: E 01ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE - BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY OATS PERMIT N0. INFO ""II ,, 1�. 00 a 5/ 5sS •1 S EH 13-24 REV. 10/82 10/82 500 14-26