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APPLICATION FOR PERMIT .*1e SAN JOAQUIN LOCAL HEALTH DISTRICT _/O� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED �Y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �/J�,,1l1� (Complete in Triplicate) �4"/V - 2q 5- aQD dZt 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 Count Ordinance se 62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, yit I � Job Address i�a ra E. /1rJiL wi p /j.�,o�v Subdivision Name Owner's Name Ci, 84yz-p/✓ Address 56we Ht Job Phone Contractor's Name 47 /9N/,4edgZ If SO/y License No. YV51- 89/ Phone 92: TYPE OF WELL/PUMP WORK: NEW WELL 1] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Y. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation G LJ Domestic/Private [-]Gravel Pack ❑Tracy Dia. of Well Casing Cw� ❑ Public ❑Other ❑Delta T Irrigation pee of Casing Li 9 Approx. �Eastern Specifications Cathodic Protection Depth Depth of Grout Seal ❑Geophysical 17 Other Type of Grout Surface Seal Installed by J Repair Work Done ❑ Type of Pump H.P. State Work Done p Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') V r' V TYPE Of SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence L Commercial _ Other Number of living units: I Number of bedrooms 3 Lot size Character of soil to a depth of 3 feet: .SA.Vel Water table depth //0 SEPTIC TANK (ZJ Type/Mfg Qyp Ci/5;7 Caw, Capacity //00 No. Compartments W- PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION C] LEACHING LINE NJ No. 8 Length of lines Total length/size .7 /D FILTER BED Distance to nearest: Well 900 Foundation YS' Property Line lea SEEPAGE PITS [] Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 workman5 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 mu ca 71 for 1 required inspections. Complete drawing on reverse side. Signed X' `/^/1 Title: Date: FOy ICRTM'R USE ONLY / Application Accepted by J Area/�---y�(y�� ❑ Stk -A66-6781 Additional Comments: Sd7 K ❑ Lodi 369-3621 Pit or Grout Inspection ,T— Date LX Manteca 823-7104 .fd I'4 II C. Final Inspection by Date 2 (,[. L-1Tracy 835-6385 //p.7r.{r7r/o/rrL Applicant - Return all copi o: nvironmental Health Permit/Services 1601 E. Hazel on Ave., P.O. Box 2009, Stk., CA 95201 /i o, roLIc FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. L. i_tY4 C,ai Sej INFO DCJ EM 13-24 REV. 10/82 (� 10/82 500 14-26 t