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APPLICATION FOR PERMIT Q SAN JOAQL!N LOCAL HEALTH DISTRI T 0�{4 �J^J i 1601 E. HAZELTON AVE., STOCKTON, CA I'1l� � PERMIT NO. ` Telephone (2 b9) 466-678I , DATE ISSUED _�-.- PERMIT EXPIRES 1 YEAR FROM DATE ISSURQN JCAQUIN LOCAL (Complete in Triplicate) HEALTH DISTRICT 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 Regulations of Phe San Joaquin Local Health District. r > � Job Address // Subdivision Name /�� .0/% Owner's Name _xffAe;X&t2Address Pho a s 51 i Contractor's Nam + 03 icense No. 49� 76 9 Phone - f ' I TYPE OF WELL/PUMP WORK: NEW WELL F-1 WELL REPLACEMENT LJ DESTRUCTION PUMP INSTALLATION - SYSTEM REPAIR L7 OTHER Q W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEQJ 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� Industrial U Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private Gravel Pack [—I Tracy Dia. of Well Casing V El Public FJ Other E] Delta Type of Casing FJ Irrigation Approx. Eastern Cathodic Protection Depth Specifications Depth of Grout Seal , Geophysical I Type of Grout U Other Surface Seal Installed by Repair Work Done Type of Pump N.P. State Work Done Va. Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: 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 CI Type/Mfg r Capacity, ,__ -No. Compartments I PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal f SEWAGE SYSTEM c�iDistance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number i SUMPS 1J Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Ll 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's compensation laws of California." I 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 applica must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FO RTMENT USE ONLY App kation Accepted by Area �— tstk 456-6781 Additional Comments: odi 369-3621 Pit or Grout Inspection by Date 1L Manteca 823-7104 Final Inspection by Date /� 'l� ❑ Tracy 835-6385 I 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 PERMITNO.FO �pr _j7 EH 13-24 REV. 10/82 10/82 500 14-26