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# APPLICATION FOR PERMIT SA.N JCAQU;,d LOCA'. HEALTH 5iSTR1CT -�q h f 1601 E. HAZLLTON AVE„ STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES i YEAR FROM DATE ISSUED i (Complete in Triplicate) ' !` Application is hereby made to the San Joaquin Local Health District for a permit to cons truct 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 ,i and the Rules and Regulation f the San J aquir Local Health District. , Job Address S Subdivision Name Owner's Name //t0 Address _S7441417 /1°2 " �k/Bf! ne 7� Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION W PUMP INSTRLLR SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST#SEPTIC TANK SEWER LINES D15POSAL<FLD, PROP. LINE + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t❑ Industrial ,.. ,F-_1 Open.Bottom •❑Manteca-#'" "'~ "Dia: of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑Other ❑Delta Type of Casing ! Lj Irrigation APprox"- Eastern Specifications ` ❑Cathodic Protection Depth /� / Depth of Grout Seal ❑Geophysical /(/ I , Type of Grout r f_1 Other t Surface Seal Installed by E U � Repair Work Done E] Type of Pump H.P. ... .State-Work Donei Well Destruction F1 Well Diameter #Sealing�Material (top 50') _ — 'F Depth _Filler Material (Below 50'} LR TYPE OF SEPTIC WORK: NEW 1N5TRLLATION F1REPAIR/ADDITION ❑ (No septic7tank or seepage pit permitted if public sewer is available within 200 feet.) k / Other Installation will serve: Residence Commercial ' ► Number of living units: �_ Number of bedrooms � Lot size Character'of soil to a depth of 3 feet: eA Water table depth � SEPTIC TANK g Type/Mfg Capacity (O No. Compartments .2 _ M PKG. TREATMENT PLT. ❑ Type/Mfg I. Capacity Method of Disposal o SEWAGE SYSTEM Distance to nearest: !Well I Foundation Property Line DESTRUCTION r r LEACHING LINE ❑ No. & Length of lines Total length/siz e i FILTER BED ❑ Distance to nearest: 'Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number t I) SUMPS ❑ Distance to nearest: Well Foundation �� '; Property Line DISPOSAL PONDS ❑I ' 1' L e 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 i n in such manner as to become subject to workman; compensation laws of California." permit is issued, I shall not employ any perso . f certifies the following: "I certify that insthe performance of the work for which Contractor's hiring or sub-contracting signature this permit is issued, I shall employ persons subject to workman's compensation laws of California." pThe applU44� ui d inspections, Complete dr//aing an reve e s?ide. IV— Signed X Title: C/� F ' Date: F DEPkRTMENT USE ONLY Q =T Stk 466-67 Application Accepted by Area �� ❑ Lodi 369-3621 1 Additional Comments: ❑ ate Manteca 823-7104 Pit or Grout Inspection by Tracy 835-6385 Final Inspection by Date y.7/r L7 t—o Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Replicant - Return all copies St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ys �' y 10/82 500 EH 13-24 REV. 10/82 14-26