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{ a4 - APPLICATION FOR PER.M17' i SA.N IOAQUiN LOCA_ HEALTH DISTRICT 1601 E. HAZELTON AVL., STOCKTON, CA PERMIT NO. T3, F Telephone (209) 466-6751 ,p DATE ISSUED 1 0 k 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 ioaiuin Local Health District. - -} Job Address_q4o.D Subdivision Name Owner's Name Address Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [J DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO,NEAREST: SEPTIC TANK SEWER LINES-2 ,A DISP05AL FLD. PROP. LINE FOUNDATION l AGRICULTURE WELL OTHER WELL `� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 06 17- Industrial ❑ Open Bottom Manteca Dia, of Well Excavation F ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. .of Well Casing I Public F-1Other ❑ Delta Type ofd Casing V Irrigation 1 Approx. Eastern Specifications Cathodic Protection �• E] 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 a 1. ' Well Destruction 13 Well Diameter Sealing Material (top 50') -Depth..— Filler Material (Below 50') 1 i lrhJ, TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ w REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is + I available within 200 feet.) Installation willfserve: Residence Commercial _ Other s Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: # Water table depth ig e No. Compartments e SEPTIC TANK Type/Mf -"° Y Capacity p i PKG. TREATMENT PLT. [l Type/Mfg Capacity {"�- . Method of'Disposal `�`��" SEWAGE SYSTEM Distance to nearest Te Well Foundation Property Line DESTRUCTION ❑ I I _. k - " LEACHING LINE U No. & Length of lines 8� Total length/size Q FILTER BEDDistance,to nearest: Well // �Q Foundation (� Property Line SEEPAGE PITS ❑ De pth�7_� _ Size �,? Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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. i 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." I 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 applicantmu c 1 for 1 required ins ctions. Complete drawing on reverse side. Title: Date: Signed X �� F3 R DEPARTMENT USE ONLY Area lj ❑ Stk 466-6781 Application Accepted by , Additional Comments: L] Lodi 369-3621 Pit or Grout Inspection by Date _- _�3 U Manteca 823-7104 Final Inspection by Date Y Z F'7F 5, ❑ Tracy 835-6385 Applicant - Return all c o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUN7j DUE AMOUNTREMITTEDRECEIVED BY + DATE PERMIT N0, INFO 10/B2 500 EH 13-24 REV.. I0/82 14-26