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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT "- a 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781iw _ PERMIT EXPIRES 1'YEAR FROM DATE ISSUED DATE ISSUED i (Complete in Triplicate) II Application is hereby made`lIo the San Joaquin Local Health District for a permit to construct and/or install the work herein I 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. Job Address wj�cl Subdivision Name � Owner's Name n— efAffPl Address Contractor's Phone �Z� Name �� License No. Phone i ;F a ! TYPE OF WELL/PUMP WORK: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ U'� a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIClTANK SEWER LINES DISPOSAL FLD, PROP. LINE 1 FOUNDATION AGRICULTURE WELL 07NEA WELL PITS/SUMPS t INTENDED USE II TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation },} ❑ Domestic/Private ®Gravel Packv ❑ Tracy Dia. of Well Casing I ❑ Public Other ❑ Delta L, Irrigation J❑ Type of Casing Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth p ❑Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by Repair Work (lone ❑ Type of. Pump H.P. State Work Done 4 Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth �I Filler Material (Below 501) 7r- TYPE p.TYPE OF SEPTIC WORK: NEW INfSTALLATION ❑ REPAIyR/AIT+ON (No septic tank or seepage pit permitted if public sewer is I. Installation will serve: .Residence _ Commercial "'>( Other " available within 200 feet.) Number of living units: Number of bedrooms Lot site ty F� Character of soil to a depth of 3 feet: Water table depth F SEPTIC TANK ( Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: .Well Foundation Property Line e DESTRUCTION ❑ IM LEACHING LINE ❑ Nol' & Length of lines. ry Total length/size' FILTER BED ❑ Distance to nearest: Well �.lL ►Foundation Property Line p. tt SEEPAGE PITS ❑ Depth Size Number f SUMPS ❑I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I Hereby certify that I have Tprepared 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'Fs 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 thispe is issu (/,> ed, I shall employ person subject to workman's compensation laws of California." ► The pplic nt must call II equired ctions. Complete dr wi rever side. w Signe iN Title: Date: 1 J d I� NT U Application Accepted by "'" ea 44 Stk 466-6781 1 Additional Comments: .�� C� ❑ Lodi 369-3621 Pit or Grout Inspection by Datet 7 Manteca 823-7104 Final Inspection by !� Date 7 -/,r- tr Tracy 835-6385 Applicant - Return all copies to; Environmental Healt6,Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95202 I� FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. �. INFO .F. 144S -�-n `Z �3 3--73 EH 13-24 REV. 10/82 _ 6 /1 10/82 50014-26 �? i