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y u APPLICATION FOR PERMIT SAN JCAQUiN LOCAL HEALTH DISTRICT �� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED o?°1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 Subdivision Name D Owner's Name �.b.`�6 �7�C Address Phone Contractor's Name License No. Phone TYPE Of WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F DESTRUCTION ❑ '3ky,�%_.>PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER i DISTANCE TO NEAREST: SEPTIC TANK �.�p SEWER LINES DISPOSAL FLD. PROP. LINE +~ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial pen Bottom ❑Manteca Dia. of Well Excavation \A14_1 Faomestic/Private 0 Gravel Pack Tracy Dia. of Well Casing Q" Public F-10ther Delta Type of Casing 'Iz��r4-4;—\ V IrrigationApprox. Eastern Specifications Cathodic Protection Depth E] Depth of Grout Seal 49_� ❑Geophysical Type of Grout 01. Other Surface Seal Install ed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well DiameteP' Sealing Material (tap 50') — Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is {� available within 200 feet.) rte, Installation will serve: Residence _ Commercial _ Other �} 1 Number of living units: Number of bedrooms Lot size Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size + FILTER BED Distance to nearest: Well Foundation Property Line I SEEPAGE PITS Depth Size Number ' SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C� 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 applicant must call for all required inspections. Complete drawing on reverse side. C.�v�a�) Date: Signed X - � &P�ARTMENTT�USEONYApplication Accepted by , Area Stk 466-67$1 AAAt� ,&- Additional Comments: c� Lodi 369-3621 Pit or Grout Inspect*to: Environ Date 8 Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copi ent I Health Permit/Services 16 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE =PERMIT INFO ��_/ 1 el �j 110`-/922 500 EH 13-24 REV. 10/82 Y� 14-26