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_ r r ^ 1601 E. HAZELTON AVE., STOCKTON, CA PERPtiT,N0. C Telephone (209) 466-5781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) F 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 JoaLocal Health District. I y Job Address 3 t qui Subdivision Name Owner's Name Address Phone Contractor's Name icense No. Phone C L i TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTICN ❑ } ' PUMP INSTALLATION SYSTEM REPAIR OTHER El E DISTANCE TO NEAREST:.SEPTIC TANK e0 r SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � � a J Industrial U Open Bottom Manteca Dia. of Well Excavation F omestic/Private `ravel_ Pack Tracy Dia. of Well Casing s �� Public Fj Other Delta Type, of Casing �Z L i Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout S�f a ❑Other t ,� � Surface seal Installed by�l CCO 6A Repair Work Done ❑ Type of Pump ''t H.P. state Work Done //J.A T_0 L Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 5O') TYPE OF SEPTIC WORK; NEW INSTALLATIONN-711 REPAIR/ADDITION jJ (No septic tank or seepage pit permitted if public sewer is : available within 2,00 feet.) �} Installation will serve: Residence _ 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 Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal 1 SEWAGE SYSTEM Distance to nearest: Wel l_ Foundation Property Line z C DESTRUCTION LEACHING LINE j=f No, & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line F3 SEEPAGE PISS ❑ Depth Size Number F, SUMPS Ll Distance to nearest: Well Foundation Property Line tt DISPOSAL PONDS ❑ ^ 1 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. Hume 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 P -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 applic mus ll r al it inspections. Complete drawing on reverse side. ? �{ Signed X , d Title: Oates; d OR ARTMENT USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: � P ph Lodi 369-3621 Pit or Grout InspectioA �w' PU.A h Lf Date 7 Manteca 8234104 Final Inspection by Datei3 L7 Tracy 835-6385 Applicant - Return all copie�tZ: 'F.. ironmental Health Permit/Services 1601 E. Hazelton Ave— P.Q. Box 2009, Stk., CA 95201 F,;. FEE BASE AMOUNT�IE AMOUNT REMITTED RECEIVED BY DATE' PERMIT NO. INFO �— 2 SOC • LH-13-24 REV. 10/82 14-26