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APPLICATION FOR'PERMIT 0] SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZELTON AVE., STOCKTON,.CA -, PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED (Complete in Triplicate) i 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 Regulat' in Local Health District. A p .%tiJ= �s Job Address Y4,410 br Subdivision Name ; Owner's Name vB. Address ' ht t + " Phone Contractor's Name ArAego1r SO License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENTL[] -,%DESTRUCTION ❑ I PUMP INSTALLATION ❑'`—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 CONSTRUCTION SPECIFICATIONS `. ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Trac n—"'-" Dia"of Well-Casing ❑ Public ❑Other ❑ Delta Type of Casing irrigation Approx. ❑ Eastern Specifications _k ❑ Cathodic Protection Depth ti ; Depth of Grout Seal (]Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of PumpH.P. State Work Dane Well Destruction Well Diameter Sealing Material (top 50') _ '1 i Depth Filler Materia-llt(Below`50') GN r iTYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑-(LNo septic tank or seepage pit permitted if public sewer is �- u available within 200 feet.) Installation will serve: Residence .`/ Commercial _Other Number of living units: �_ Number of bedrooms Jr tat size • ti Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK EY] Type/Mfg !!nAC T Gvwr `'Capacity 64jee, No, Compartments PKG. TREATMENT PLT. ❑ Type/Mfg "Capacity Method of Disposal - SEWAGE SYSTEM Distande to nearest: Welli!'/,4 Foundation /0 Property Line jt'O ' DESTRUCTION Q -- LEACHING LINE U No. & Length of lines w ' Total length/size 16 O f ` FILTER BED ❑ Distance to nearest: Well ! Foundation A-4- Property Line —If— SEEPAGE SEEPAGE PITS ❑ Depth Size 'r Number SUMPS LJ 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. 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 mus call for all required inspections. Complete drawing on reverse sfde'. _ Signed X= _ Title: + - = Date: � z s FOR DEPA TMENT USE ONLY _`ri `7 Application Accepted by _Areaq"_-_d E] 5tk 466-6781 k Additional Comments: ❑ Lodi 369-3621 .r I Pit or Grout Inspection.-by - Date j� Manteca 823-7104 Final Inspection by w 4 } date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-2fi _ -