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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. �5- Telephone (209) 466-6781 DATE ISSUED '�S !� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED { (Complete in Triplicate) r 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 Joaquin Local 'Health District. # Job Address _9 �'_/�UJffeg"')> aypir Subdivision Name Owner's Name jex JOA100 *• Address N50,-m& Phone 931 -�„ /0 Conthti%ltAl%ame p AO ,Ii 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 FLD. -"' PROP. LINE FOUNDATION __ZtO,f AGRICULTURE WELL OTHER WELL"'r PITS/SUMPS Z".'.' / 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom Manteca Dia. of Well Excavation 10 !/✓Cid Domestic/Private .4 Gravel Pack Tracy Dia, of Well Casing 4 /n/d/f ❑ Public F-1 Other ❑ Delta Irrigation Type of Casing ation LJ 9 Approx. Eastern - 4 Cathodic Protection Depth Specifications ❑Geophysical F Depth of Grout Seal _ v cr= 7—Type of Grout ^ / ; '� Surface Seal Installed b•. . �r/��JT'_� v � Repair Work Done ❑ Type of-Pump • .LJ H.P. �� State Work, e V ry: Well Destruction F-1 Well Diameter Sealing Material (top 50')_- - r Depth Filler Material (Below-50') CZ TYPE.OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (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: I Number of bedrooms Lot size Character of soil to,a depth-of 3 feet: Water table depth t I° SEPTIC TANK -Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal - A SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line W DESTRUCTION ❑ P y LEACHING LINE No. & Length of lines Total length/size { FILTER BED - Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line / DISPOSAL PONDS ❑ E " 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 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 issued, I shall employ persons subject to workman's compensation laws of California." The applic t call or 11 required inspections. CompleteWdr�w�, on ver/se side. Signed X '!i ` Title; +YV / y !?N'T1�1 ��0 Date: EPARTMENT US NLY 00 Application Accep d by Area Stk 466-6781 Additional Comments: 1- —6;7_Y1'2h Lodi 369-3621 Pit or rou)lnspection Dat", O-E ❑ Manteca 823-7104 Final Inspection.by Date � �} Tracy 835-6385 Applicant - Return all copies o: Environmental Health Permit/Services 1n five., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE - AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I INFO EH 13-24"*REV. 10/82 10/82 500 14-26