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APPLICATION FOR PERMIT. - SAN JOAQUIN LOCAL HEALTH DI5TRICT 9 1601 E. HAZELTON AVE., STOCKTON, CA,� PERMIT N0. Telephone (209) 466-6781 ' .. . r DATE ISSUEDPERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) " 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 and the Rules and/ a ulations of the San Joaquin Local :Health District. Job Addresa 7 a Subdivision Name Owner's Name 4 Address _ �_ ' 4f 1.1.E Phone Contractor's Name T ,L�C�G License No: Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 5 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ D15TANCE TO NEAREST: SEPTIC TANK SEWER LINES -- AISPOSAL FLO. PROP.. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation E U Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing,- s` ❑ Public ❑ Other 1w ❑ Delta �---e Type of Casing U Irrigation Approxi ❑ Eastern �e ith l k U � Specifications ^_; ❑Cathodic Protection Pr "----Depth-of Grout,Sea Geophysical y . Type of Grout ` r LJ Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done i Weld Destruction ❑ Well Diameter Sealing Materaal"(Gap 50') Depth +% ( , Fila�er Material., Below 50') f _ y}Q� = a yup TYPE OF SEPTIC WORK: ;NEW--INSTALLATION "REPAIR%ADDITION W!'{No septic tank or seepage pit permitted if:public sewerris, available within 200 feet.) ':_) �Installation.will serve: ' Residence t_ Commercial _ Othelr Number of living units: _�_ Number of bedrooms Lot size _ �' t Character of soil to a depth of-3 feet: Water table depthi SEPTIC TANK El Type/Mfg 1 apacity � No. Compartments ! i2_ P PKG. TREATMENT"PLT. ❑ Type/Mfg s ) Capacity Method of Disposal SEWAGE SYSTEM . ?, ' Distance to nearest:""�W i'�l t Foundatioi:-, , f"Property Line i DESTRUCT ION 'i�' 1 C►qe\ f i LEACHING LINE ' No. & Length of'li"nes �J`C7 tF ( 'Total length/size --r- r / FILTER BED ❑ Distance tonearest: Well f! Foundation. Property Line SE)EPAGE PITS ❑ DeplI� - (?=1 ` _ Size O:Number..-:.......-...._ f SUMPS 0Utnce to.nearest: Well _/�ioundation � �ropert Li�ie X; } DISPOSAL PONDS ❑ I a I hereby certify that_11I have prepared this application and'that`the work W.14 be done in accordance with SanjJoaquin county ordinances, state laws, and rules and regulations of the.San-Joaqu"in ILoca1 Health District. i i Home owner or licensed agent's[signature certifies the following: "I certify that in the performance of the work for which this f+ 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 th'e performance,of the work for which this perfifr `,J's.i`ssued, I shall employ persons subject to workman's compensation laws of Califor'nia.." . The applicant must' 11 ,for all, re fired • spections. Complete drawing on reverse side, I 1 SignedX fltl e': �',llv�� , Date: f`�c a ! - TMENT:USE,ONLY._, ._„E,,,. jl Application Accepted by ®_�� Area= f , Stk 466-6781 Additional Comments: j❑ Lodi - 369-3621 Pit or Grout Inspection by Date ,} Manteca 823-7104 Final Inspection by Date ❑ Tracy 895-6385 Applicant - Return all copies to: Environm n 1 Health Permit/Services 1601 E. Hazelton Ave.f P.O. Box 2009,1 Stk„ CA 95201 FEE BASE 7AMOUNT'"IDUE AMOUNT REMITTED RECEIVED BY DATE PERMIY N0. INFO 7 ."�...".-EH"13-24".'REV.-10%82.._".,".� — �`-...P•.•�...,. --_..__�_. �T ...__�-10/$25DO + 14-26 1