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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT a �� { 4 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. } Telephone (209) 466-6781 DATE ISSUEDI PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f ' ( 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 a and the Rules and Regulations of the San Joaquin Local Health District, Job Address < < �� ; Subdivision Name Owner's Name ffAddress Phone Contractor's Name S_ �. License No. 5:7-1331 Phone r TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ F PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U (1`1 f DISTANCE TO,N_EARE_S_T-: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE } I,.. FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS 11 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r`r '�)}} Industrial U" J lJ Open Bottom ❑ Manteca Dia., of Well Excavation Domestic/Private F_j Gravel Pack LD Tracy Dia. of We13 Casing Public F-1 Other [].Del to L Irrigation {, Type of Casing i g Approz. n Eastern Depth Specifications 4 � Cathodic Protection, Geophysical Depth of Grout Seal ..... � Type of Grout v' 1 ❑Other Surface Seal Installed by (/� Repair Work Done [�' Type of Pump -H:P. State Work Done .IJ Well Destruction U _ Well Diameter Sealing Material (top 501) .� 7 .Ar Depth Filler Material (Below 50') r - f TYPE OF SEPTIC WORK: NEW INSTALLATION �j REPAIR/ADDITION ❑ .(No septic tank or seepage pit permitted if publicfseweir is Installation will serve: Residence v1 available within 200'feet.)Commercial _ Other - v11 Number of living units: ti Number of bedrooms Lot size r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity � � No. Compartments 2 + PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal SEWAGE SYSTFM Distance to nearest: Wel lt-7_op t4- Foundation Property Line + ' DESTRUCTION ❑ r� LEACHING LINE . Lt.�- No. &Length of lines �3 - o Total length/size Z x FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS S�r DepthSize 18 WAS Number SUMPS L—I Distance to ne est: Well �,n� , f Foundation �_ Property Line DISPOSAL PONDS ❑ yam 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 s..-,�, ,�,,r,pe-rmitrislissued, I shall rot 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 apps' must call f 1 all requir d inspections, Complete drawing o reverses e. r Signed X . Title: �v'r ; � Dater-� FOR DEPARTMENT USE ONLY-` ' Application Accepted by W TT Area �� Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date LV Manteca 823-7104 Final Inspection by � k _ Date 3� �/ L Tracy 835-6385 o: Applicant - Return all copies tEnvironmental Health Permit/Services 1601 E. Hazelton Avlle., P.D. Box 2009, Stk., CA 95201 FEE BASE aAMOUNT DUE ' AMOUNT REMITTED RECEIVED BY DATEPERMIT 'F3—PERMIIjT N0. INFO �O� U3~ f 7� EH 13-24 REV. 10/82 10/82 500 14-26