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� � iN __ _ _ .. moo. •�-r APPLICATION FOR PERI1f1T iSAN JDAQUitl LOCAL HEALTH DISTRICT �f P 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 u DATE ISSUED f 0 PERMIT EXPIRES 1.YEAR FROM DATE ISSUED (Complete in Triplicate) 13 ��{�(�C7�-Q�' 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 Reguiatians of the San Jo quin Local Health District. / Job Address 4ci f AM 4774.e Subdivision Name ,eDue� 4�- --a Owner's Name Address . ,I Phone Contractor's Name License No. y phone (,A/T'AG r +< TYPE OF WELL/PUMP WORK: jI NEW WELL WELL REPLACEMENT DESTRUCTION ! W PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER U 013 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE .v FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r 4 INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j J Industrial I U Open Bottom' Manteca Dia. of Well Excavation 01 I U Domestic/Private ��Q Gravel Pack Tracy Dia. of Well Casing { L� Public IP[—i Other Delta irrigation �° EJ Eastern of Casing LJ g Approx. Eastern Cathodic Protection Depth Specifications Depth of Grout Seal 17 Geophysical Other p Type of Grout Surface Seal Installed by Repair Work Done ❑ Type lof Pump H.P. State Work Dore I Well Destruction U Well Diameter Sealing Materialtop 50') Depth:- Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW?:INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will served Residence _ Commercial Other u3 Number of, living units: Number of bedrooms Lot size jh Character of soil to a depth of 3 feet: Water table depth + SEPTIC TANK Type/Mfg Capacity No. Compartments I, PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION E LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SLEPAGE PITS Depth � .� Size S Number , SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ % 7 I+1 I li li'Il� lli I II�IIIIY� I n� —- __ mlin�nnili� � 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 subs'-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I steal mplo persons subject to workman's compensation laws of California." The applicant mu c 7 all a ed spections. Complete drawing on euerse side, 4 Signed X Title: Date: � 'I FOR PARTMENT USE ONLY Application Accepted by Area _ ® Stk 466-6781 "Y Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date 3� // ^Y� Manteca 823-7104 Final Inspection byl Date L7 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. 1 INFO i f � 3 t3- l�SI EH 13-24' REV. 10/82 I 10/82 500 14-26 .� 1