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I V, APPLICATION FOR PERMIT`" SAN JDAQUiN LOCAL HEALTH DISTR ... �„ ,,,o „y , 1601 E. HAZELTON AVE-, STOCKTON, CA `AN '' ��`'= PERMIT NO. Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUC-��,, IAN JOAQ 'lN LO'CA_DATE ISSUED 1 S g (Complete in Triplicate) HEALTH DISTRICT 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 1 and the Ru es and Regulations of the San Joaquin Local Health District. Industrial ;__Open Bottom Job Address 'L EA Q - Subdivision Name /� (q / A6 " ir' / �-p ✓ ❑ Public Owner's Name A 6S . Address SAlY6"e ❑ Phone x'38 contractor's Name ""�zS « License No. .2 ®/ Phone3P-�z��i TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION [J SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA Industrial ;__Open Bottom ❑ Manteca Domestic/Private 0 Gravel Pack ❑ Tracy ❑ Public G Other ❑ Delta CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing Type of Casing ' f—jIrrigation Approx. [] Eastern Specifications F-1CathodicProtection Depth 1-1 Geophysical Depth of Grout Seal Type of Grout E❑ Other Surface Seal Installed by % Repair Work Done PK Type of Pump H.P. State Work Done %.,cr cc < Well Destruction F-1Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ell REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) - Installation will serve: Residence _ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Type/Mfg SEWAGE SYSTEM Distance to nearest:. Well DESTRUCTION 0 - Other Lot size Capacity Capacity Foundation Water table depth No. Compartments Method of Disposal Property,Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑I 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 s cal for�L� ctions. Complete draw i ev se side. r1 Signed X r Title: Date: 4r� yc '�7 b 67 Application Accepted by /1-1F DEPARTME USE OSLBy Area 464�- ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date -�. anteca 823-7104 Final Inspection by - Date Ln Tracy 835-6385 Applicant - Return all copies to:. bA ronmental Health rermit/Services 1601 E. Hazelton Ave., T.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY. DATE PERMIT NO. INFO FH 13-24 REV. 10/82— 10/82 500 14-26��.