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! 0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �� ' Telephone (209) 466-6781 GATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `i (Complete in Triplicate) ' 9 Application is hereby made1yto the San Joaquin Local Health District for a permit to const an or to N,. EfDp described. T1yis�ap k1i n is made in compliance with San Joaquin County Ordinance 49 ew or I and the Ru'e R nss&� San Jo�uin Local Health District. Job Address li/5R >V ASS _ Subdivision Name . f of Owner's Name &99-1-Akr AS Address one ' Contractor's Name, se License No. Phone TYPE OF WELL/PUMP''WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ,{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. .LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE °'' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑Manteca Oia. of Well Excavation U Domestic/Private I ❑Gravel Pack []Tracy Dia. of Well Casing 17 Public ❑Other`. ❑Delta Type of Casing Irrigation Approx. ❑Eastern Specifications ❑ Cathodic Protection , �' Depth 1 Depth of Grout Seal ❑Geophysical Type of Grout Other Surface Seal Installed by �\ Repair Work Done ❑1 Type:of Pump H.P. State Work Done Well Destruction ❑ Well:-biameter Sealing Material,.(top 50') - Depth. Filler Material (Below 50') .� TYPE OF SEPTIC WORK: NEWJNSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is e'j�" _available within 200 feet.) --- install ation--wi-1-l-serve:`Residence---Commercial,;-_-Other- - -- - -----------�-_- - - -- - - j Number of living units:l� h Number of b drooms Lot size Character of soil to a-depth of 3 feet: � Water table depth SEPTIC TANKCType/Mfg Capacity t� No. Compartments PKG. TREATMENT PLT. ❑ II'pType/Mfg Capacity Method of Disposal SEWAGE SYSTEM ,Distance to nearest: Well Foundation Property Line DESTRUCTION C] �' LEACHING LINE ❑ a INo. & Length of lines Total ilength/size / 4 Aggok FILTER BED ❑ �Oistance to nearest: WellJ7Q IrEoundatinn f® - Property Line SEEPAGE PITS ❑ 1IDepth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONOS I hereby certify thatI"Piave prepared this application and that the work will be done in accordance with San Joaquin county 1 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 shallinot employ any person in such manner as to become subject to workman 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 loy;persons'subject to workman's compensation laws of California." E 'The applica t must call'for al r uire inspections. Complete drawing on reverse side. ��77 7 ' Date: ZA 7 Signed a Title: F DEPA=TNT USE ONLY Replication Accepted by Area._ _ E] Stk 466-6781 Additional Comments: ElLodi 369-3621 Pit or Grout Inspection by Date El Manteca 823-7104 Final Inspection by Date 71 ❑ Tracy 835-6385 Applicant - Return all copies to: Environ Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 r pp FEE BASE '! OUNT DUE AMOUNT REMITTED [WRVEDBY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500