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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTS 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. J 1 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUER (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w2 for'rell described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No.. 1862 or'well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Subdivision Name Owner's Name ' Address Phone -,3S�—�J � Phone �7� Contractor's Name' License No. Z TYPE OF WELL/PUMP WORK: NEW.yWELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ w PUMP INSTALLATION P4.. SYSTEM REPAIR ❑ OTHER SAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL THER WELL PITS/SUMPS V" FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y Industrial ❑open`Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private F1Gravel Pack []Tracy Dia, of Well Casing Delta ❑ P.ublic ❑Other ❑ Type of Casing Irrigation Approx. ❑Eastern Specifications ' ❑Cathodic Protection .Depth Depth of Grout Seal Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction E3Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50;) - :.�+�� is TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No.septic tank or seepage pit permitted if public sewer JT available within 200 feet.) Installation will serve: Residence _ Commercial Other. Number of living units: Number of bedrooms Lot size t Character of soil to a depth o'f�3 feet: Water table depth SEPTIC TANK F-1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Septic 'Tank Distance to nearest: _Well. -. Foundation _ Property Line LEACHING LINE ❑ No. & Length of lines %' k.Total length/size FILTER BED ❑ Distance to nearest: .Wel-1 Foundation Property Line !' SEEPAGE PITS E3Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the wort will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r+ Home owner or licensed agent's signature certifies the following: "I certify that in the performance ns tion lawork for which this l permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." Ili Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance`of the work for which i this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicantAmpt call f r all requir2 inspZc ions. Complete drawing on rhemjErae Sid, Title: [�—�s� Date: Signed x - F EPARTMENT USE ONLY 0 E]Area -7 Stk 4666781 Application Accepted by /� ❑ Lodi 369-3621 Additional Comments: ate ❑ DManteca 823-7104 Pit or Grout Inspection by F` 3 Final Inspection by Date �f Z�-� ❑ Tracy 835-6385 Applicant Return all copies to: EnvirfrAental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE p PERMIT NO. INFO 5 C4 �3 d 3-31 1 10/82 500 EH 13-24 REV. 10/82 e 14-26