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s �l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH,DISTRICT 2 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 , DATE ISSUED 6 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ap (Complete in Triplicate) Applicatior 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 Reulations f the n Joaquin Local Health District. Job Address CSubdivision Name ' Owner's Name dress 0/�cls;l Phone Contractor's Name }c- License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ �Il PUMP INSTALLATION SYSTEM REPAIR OTHER U 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 J Industrial U Open Bottom (]Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public Other Delta Type of Casing Ljirrigation Approx. [] Eastern Depth Specifications Cathodic Protection Depth of Grout Seal Geophysical Type of Grout U Other Surface seal Installed by Repair Work Done [JJ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC.WORK: NEW INSTALLATION U REPAIR/ADDITION No septic tank or seepage pit permitted if public sewer is �} available within 200 feet,} Instal3ation will serve: Residence _v Commercial _ Other Number of living units: _-.-/-__ Number of bedrooms —Z-- - jLot size Character of sail to a dep of 3 f et: f'5 e `"ea', Water table depth SEPTIC TANK T40-o" Z - /f� "i.��it� __ Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Wel l__. Foundation �._ Property Line Q / DESTRUCTION LEACHING LINE No. & Length of lines — d Total length/size FILTER BED ` " Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS Depth .0 Size 0 `�^ Number SUMPS Distance to nearest: Well F Foundation S-5 t Property Line .301 DISPOSAL PONDS �1 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 workman5 compensation laws of California." Contractor's hiring or sub-contrac ing signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em oy pe sons subject to workman's compensation laws of California." 3 The applicant ust 11 f all inspections. Complete drawing on reverse side. Signed X Title: (.(f3Lh Date: FOR EPARTMEN U 0 Y �1r1 Stk 466-678 App ication Accepted by l //7s � Area ��_ , W Additional Comments: f! ` 4(, Lodi -3621 Pit or Grout Inspection by Date J `/S�d'3 a Manteca 823-7104 Final Inspection by Ae Date /f-�3 [❑ Tracy 835-6385 Applicant - Return all Copies L to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DAT-Ep .q PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 t :. .