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�oID ' APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 y PERMIT EXPIRES 1 YEAR FROMDATE ISSUED DATE ISSUED (Complete in Triplicate) rplication is hef,?6j' made to t e-33 nn Joaquin Local Health District for a permit to construct and/or install the work herein :scribed. This application is made in compliance with San' Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump ed the Rules and Regulations of a SanJo qui ocal Health District. ib Address mer's Name ro&gAddress _ Phone ntractor's NameLicense No. 417 Z Z Phone YPE OF WELL/PUMP WORK: NEW WELL ® WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION g. SYSTEM REPAIR OTHER ❑ [STANCE TO NEAREST: SEPTIC TANK urJ 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 Dia. of Wall Excavations ~ Domestic/Private ® Gravel Pack_ _,Tracy Dia, of Well Casing " Public Other Delta Irrigation-,...... — 06 / Approx. ❑ Eastern- Type of Casing � �, �. Depth Specifications Cathodic Protection P Geophysical Depth of Grout Seal Other '`J Type of Grout Surface Seal Installed by jaLuj _ %.-, air Work Done [:]Ty¢e of Pump — H. P. /f State Work Done 1 Destruction E] well Diameter --- (o-" Sealing Material (top 50') _ Depth 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of sail to a depth of 3 fleet: Water table depth SEPTIC TANK EJ Type/Mfg Capacity No, Compartments Ip KG. TREATMENT PLT. C] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance ❑ to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size �ILTER SED (] Distance to nearest: Well Foundation Property Line EPAGE PITS ❑ Depth Size NPS LI Distance to nearest: Well SPOSAL PONDS �I Number Foundation Property Line 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 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 issu I shall employ persons subject to workman's compensation laws of California." The applicant must c or a I r ired inspections. Complete drawing 0reverse side p Signed X Title: ` i+.l�1— _ Date: IL OR DEPA ENTUS p' Application Accepted by (�/ 2 Area of, tk - 466-6781 Additional Comments: F F E] Lodi 369-3621 Pit or Grout Inspection by DateIJ Manteca 823-7104 Final Inspection by Date17 AV Q Tracy 835-6385 Applicant - Return all copies to: Environmental lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I BASE AMOUNT UE AMOUNT REMITTED RECEIVED BY Q DATE �rPERMIT NO. INFO Eli 13-24 REV. 10/82 10/82 500 14-25