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f - V. t� ` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Q I, 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSiIED, � kZ 4 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 workherein 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. c r Job Address (!�, �n� C Subdivision Name IF" Owner's Name Address p Phone 5,27-fj 9V Contractor's Name License No. �gQ�j'/ _ Phone '4 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA)ION ❑ SYSTEM REPAIR ❑ ` OTHER ❑ / DISTANCE TO NEAREST: SEPTIC TANK ' 1! 0One, SEWER LINES DISPOSAL FLD.lO® PROP. LINE !_ i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom 5almanteca Dia. of Well Excavation v Domestic/Private IRtravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing �. Li Irrigation Approx. [] Eastern Specifications Z(20_& Yl� f ❑Cathodic Protection Depth — Depth of Grout Seal ❑Geophysical Type of Grout I U Other Surface Seal Installed by Repair Work Done ❑ Type of Pump M.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is . available within 200 feet.) ' Installation will server Residence _ commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method, of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines _/e?0 —14— Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line I� SEEPAGE PITS ❑ Depth Size Number f SUMPS ❑ Distance to nearest: Well Foundation 'Property Line (l 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. 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 applian must call for al required inspect-ons. Comple dr wing o everse side. Signed X Title: -fi Date02/ OR DEPA USE O LY r `� Application Accepted b Area 0[a ❑ Stk 466-6781 Additional Comments: EJ 369-3621 it or Grout Inspection by Date-e� - Manteca 823-71047 Final Inspection by Date ❑ Tracy 835-6385 plicant - Return all copies to: nvironmental Heath Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO tl3 c7 1 EH - RE 0 i,04*ur W, 10/82 500 14-261 U;:e CIDJ