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APP LICATION FOR.pERk':T 3 a✓ ' LOCALH-ALT DISTRICT PER4IIT N0. �1— SA.N aOAQ jL,,'� �+ 1601 E. HAZELTON AVE., STOCKTON, CH DATE ISSUED �7 Telephone (209) 4fi6i-6181 r�� PERMIT EXPIRES I YEAR FROM DATE ISSUED I .. rein (Complete in triplicate) i or install th1B62rforewell/pump for a permit to construct and/or No, { ` Lin Local Health Distruin County Ordinance No. 549 far sewage or Application is hereby made to the San JOaq described. !;This application is made in compliance with San oaq Subdivision Name phone ��'� a and the Riles-and Regulations of the 5 Joaquin L°cal Health Distr�c�' 4_0 er/ Jab Addressf h- Address phone j Owners Name JI License No. 2�� ' w Contractor's Name DESTRUCTION ❑ NEW WELL •❑ WELL REPLACEMENT ❑ ` E OTHER �I LINE. v`] I TYPE DF WELL/PUMP WORK: ❑ SYST.EM REPAIR "L`�4� OIS40SAL,FLD. `��pROP. -`` a PUMP INSTALLATION RIS .- + pITS15UMPS I ,l - o SEWER LINES OTHER WELL �--- LJ" !j DISTANCE'TO NEAREST: SEPTICiTANK �,-�-- AGRICULTURE WELL If FOUNDATION ' •' CONSTRUCTION SPECIFICAT10N5 PROBLEM AREA # _ TYPE OF WELL —ter Dia. of Well Excavation INTENDED USE _ � . Manteca + r -� Open Bottom= ❑' Dia hof Well Lasing Industrial a Gravel pack ❑Tracy a 4N { ❑ 1^i ' _ 4 U DomesticlPrivate ❑Delta Type of Casing, ❑Other ❑ Public., ❑Eastern Spe�cifications,� °"� p^ Approx. r ❑ Irrigation �Y �� Depth Depth of Grout Seal, ,e i! ❑Cathodic Protection Typexof Grout Geophysical S rface Sea lInstalled by' U Other * State:Work ii H.P. f` Repair,Work Done �J,,,FType of.Pump Sealing Material (top 50') Well Destruction ❑ Well Diameter �,� Filler Ma EeriEal (Below 50'}"`•_. '. Depth .+ ublic sewer is _ No septic tank or seepage pit permitted if p REPAIR/ADDITION ( available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION L� �* Other / t Commercial . -- y... + �""'Lot 5 i z'e �� installation will serve: Residence _��J Water table depth units: Number of bedrooms Number of living f 3 feet: No. Compartments Capacity — # Character of soil to aIrRv�o Method of Disposal e Mfg -•x :,� Capacity e ��..�- Q SEPTIC TANK Line PKG, TREATMENT P1/f, 7ype/Mfg 'Foundation 1Property SEWAGE SYSTEM �/ ❑ Distance to nearest: Well , DESTRUCTION Tbtal length/size & Length of'lines �� Property Line •_ LEACHING LINE n Stance to nearest: Well Foundation FILTER BEDX b N Number Depth � Size property Li SEEPAGE PITS Foundation �— a 1 + fjba/ SUMPS ❑1 Distance to nearest: well _ 1.Q �/ DISPOSAL PONDS ❑ prepared this application and that the work will be done in accordance with San Joaquin county I hereby certify that I have pre p "I certify that in the work California." ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature verso 1en suchs the ;mannernas to become subject to workman camp permit is issued, I shall not employ any p Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whit rsons subject to workman's compensation laws of California." this permit is issued, I shall employ pe or all required inspections. Complete drawing on reverse side. Date: �` ��2 The applicant must call f /.w Title:. Signed X G Y ❑ Stk 466-6781 FOR DEPA T ENT S Area oL- Application Accepted by Lodi 369-3621 Additional Comments: Date ❑ Manteca 823-7104 Pit or Grout Inspection Date ❑ Tracy 835-6385 Final Inspection byP,O. Box 2009, Stk., CA 95201 t Applicant - Return all copi s to: Fnvir nmental Health Permit/Services 1601 E. H elton Ave., RECEIVED BY .4 DATE PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED �Q 10/82 500 EH 13-24 REV. 10/82 14-26 _