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i� f APPLICATION FOR PEFCi1T SAH JOAQUIN :.00AL HEALTH DISTRICT r C/ 1601 i, HA'ELTOli AVE., STOCKTON, CA PERMIT ND, ! Te cphone (209) 466-678.1 DATE ISSUED —L—j nen y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (complete in Triplicate) iI 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 Saa Joaquin County Ordinance Sa. 549 for sewage or No. 1862 for well/pump i and the Rules and R l tiSa& oaquinocal/H,ea th District. Job Address s�� ! � J!•T�Subdivision Name / aOwner's Namee46Address Phone 11 Contractor's Nam* p f License No. Phonepi�/ 1 J . TYPE OF'WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION❑ 1 PUMP INSTALLATION � SYSTEM REPAIR �] OTHER 0 DISTANCE TO NEAREST: SEP'IC TANK ! SEWER LINES DISPOSAL FLD: PROP. LINE 1 Sr X FOUNDATION �f AGRICULTURE WELL _ OTHER WELL PITS/SUMPS t } INTENDED USE TYPE OF HELL PROBLEM A,1EA CONSTRUCTION SPECIFICATTONS +� � ❑Industrial �]Open Bottom []Manteca D'a. of Well Excavation 12 i�ArL if ❑DDmestic!Private �avel Pack ❑Tracy Dia. of Well Casing Xe/), b'fublic G Other ❑Delta Type of Casing Irrigation Apprnx. ❑Eastern j Depth Specifications r ;. ❑Cathodic Protection Depth of Grout Seal 3 !' ❑Geophysical Type of Grout ❑Other ,4 /k/5uace Seal Installed by Repair Work Done Type of Pump `��H.P. s6, e Work Done Well Destruction Q Well Diameter Sealing Material (top 501) " P ! Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L7j REPAIR/ADDITION [J (No septic tank or seepage pit permitted iflpublic sewer is available within 200 feet,} 7 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 ❑ Type/Mfg Capacity No. Compartments A PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: WeTi Foundation Property Line N f ' DESTRUCTION ❑ LEACHING LINE LJ No, S Length of lines Total length/size FILTER 8E0 ❑ Distance to nearest: Well Foundatiars Property Lane S' PAGE PITS Depth Size Number a SLAps LJ Distance to nearest: Well Foundation Property Line < DiSPOSAL PONDS ❑ J _ 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. 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 shtll not employ any person in such manner as to become subject to workman4 compensationhlaws of California." "C/+nt.ractor'i hiring or sub-contracting signature certifies the following: "I certify that ir. the performance of the work for which this permit is issued, I shall employ persons su:,ject to •*rkman's compensation laws of California." Theapplicant must call for 11 required insyettioris. Complete draw�inn on reverse side, L 7 iS gne6 X ?/ 1J�7 C''� Date: L i F9R DEPARTMENT USE ONLY x Application Accep d by - /12C'� _ Area / Stk 466-6781 Additio 1-*6o lits: �l .!/int t C ^c� �r �l �rsC� .n—Lndi369-362] Pit Grout Inlipection by c��.��-, Date Manteca 873-7104 �/ 7 Trac 835-G385 final Ttsliection by _��_-�.� _� Oate3 _ z�/ (� Y Appiicbnt - Return al) Copies to: �!<'n ronmental Health Permit/Services 1601 E, Hazelton Aue., P.O. Pok 2004, Stk„ CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED PECEIVED BY GATE PERMIT N0. INFO !� [ LH 13-24 REV. 10/82 M 10192 500 14-26 k ' i ,