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APPLICATION FOR PERIM'T �- i SAN JOAQLi!; LOCAL HE-.LTH ;DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED � `t PERMIT EXPIRES 1-YEAR FROM DATE ISSUED I F _ (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 ' I and-the Rules and Regulations of the San Joaquin Loc .Health District. Subdivision Name c� Job Address Phone .7 �l Owner's Name Address- Contractor's Name License No. ' Phone 3 rA TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ❑ Pl1MP INS�TFtLLRTION` ❑ YSTEM REPAIR"'"""'❑'"" "' �OiHER DISPOSAL FLO. jJ� PROP. LINE SEWER LINES DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS —w FOUNDR'ION AGRICULTURE WELL 9 �r INTENDED USE 4 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �J I Dia. of Well Excavation Industrial � ❑Open Bottom ❑ Manteca � ❑ Domestic/Private ❑ Gravel Pack [)Tracy Dia. of Well Casing r ❑ Public � �''f?❑Other [] Delta k f Type of Casing IA rox. Eastern � 3 + ❑ Irrigation � -Depth ❑ Specifications Cathodic Protection 14' Depth 14 Depth of Grout Seal ❑Geophysical Type of Grout UOther � �_ � �� ! Surface Seal Installed by r~ d of Pum H.P. fl State Work Done Repair Work Done ❑ TyP p'\ c Well Destruction ❑ We+171 giameter;' `" t' Sealing�;Material (top 50') 1 a. C Fi11er-,Mater..ial (Below SO`) r� ``� Depth L :'. t!" �f .REPAIR/ADDITION'S (No septic tank or seepage;pit permitted if public sewer is R TYPE OF SEPTIC WORK: NEW INSTALLATION I' y i available within 200 feet.) 4 Installation will server ResidenceCommercial .$Other 3 k ' Number of bedrooms._11;S*, Lot size Number of living un'its: Water table depth Character of soil to,a depftl of 3 feet: ND. Compartments SEPTIC TANK r F17YPe�M9 P Capacity PKG. TREATMENT PLT. F] Type/Mfg /I Capacity Method of Disposal SEWAGE SYSTEM ❑ Dista'ce to nearest: Well .� � Foundation Property Line DESTRUCTION '" !�/ C No. & Length of lines � � Total length/Property �_�y_, — LEACHING LINE Property Line FILTER BED Distance to nearest: Well tr ` < Foundation _. , i Depth — Size Number SEEPAGE PITS r Property Line SUMPS L 1 Distance to nearest: Well Foundation DISPOSAL PONDS with San Joaquin county T I hereby certify that' I have prepared this application and that the work will be done in accordance ordinances, state laws, and..rubes.and.,regul.a.tions,of_the,San Joaquin Local Health District. rmance of the Home owner yr liceh this nsed agent's: signature certifies suchfmannernas to become subjectthat ntohe perfo workman� compensation wlaws fof California." permit is issued, I shall not employ any p 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 person,s_`Y bjecty to workman's compensation laws of Cal efornia." rse si. The applicant 1 for all re ui d inspe ons. Complete dra 9 - Date: ' ' Title: i Signed X 1 DEPARTMENT U Area ONLY 1 <tk 466-67$1 j � • Application Accepted by ❑ Lodi 369-3621 ` Additional Comments:--^> —— -- Date ❑ Manteca 823-7104 Pit or Grout Inspection by Date Ll ❑ Tracy 835-6385 �.;�� Final Inspection by - tal Health Permit/Services I601 E. Hazelton Ave., P.O. Box 2009, 5t k., CA 9520I Applicant Return all i �o: Environmen DATE PERMIT N0. ( FEE BASE AMOUNT DUE AMOUNT REMITTED �RE,C-�E/I�VED 8Y INFO 10/82 -500 W. �{ • EH 13-24 REV- 10/82 .....�� ... = .:c....,� -..w ... __ .-_ .-..,G—•.... _,. 14-26