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APPLICATION .FOR' PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -33-1 7 P 1501 E. HAZELTON AVE..; STOCKTON, CA PERMIT NO. Telephone (2094466-6781 D 3 PERMIT EXPIRES i YEAR FROM DATE ISSUED DATE ISSOED, (Complete in Triplicate) Application is her 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 andrthe Rules and Regulations of. the San Joaquin Local Health District. Job Address_ $"00 LJ C�i[A 1' . _ Subdivision Name Owner's Name dull tpnd� FSlar Address - 0 A-) � Phone Contractor's Name -S4.04J m I-1 License No. phone •. ww TT �V TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ {,, PUMP INSTALLATION SYSTEM REPAIR LJ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES.- DISPOSAL FLO. PROP. LINE k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM'AREA 'CONSTRUCTION SPECIFICATIONS VC Industrial U Open Bottom E Manteca Dia. of Well Excavation j. U Domestic/Private Gravel Pack [—I Tracy Dia. of Well Casing Public Other L Delta Type of Casing V Irrigation Approx. [] Eastern Specifications F—ICathodic Protection Depth Depth of Grout Seal 17 Geophysical Type of Grout LJ Other Surface Seal Installed by Repair-Work Done XType•of Pump H.P. Y State Work Done " Well Destruction [J Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RE'PAIR/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 [I Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line j DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation ' a Property Line _ + SEEPAGE PITS Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS + 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 workman8 compensation laws of California." 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 applicant must call for all r 1 echo Complete drawing on reverse side. /7�kt Signed X wwal 44' itle: &P Date: OR D PART ENT U5E ONLY �a Stk 466-6781 Application Accepted by Lt q lWV-b' Area if I Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date QQ Lf Manteca 823-7104 Final Inspection by _ Date 13 3 . L7 Tracy 835-6385 tal Health Permit/Services 1601 L. Hazelton Ave., P.D. .Box 2009, Stk., CA 95201 Applicant - Return all copies to: E vironmenT FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 7 DATE q -p PERMIT} N0. INFO A , 1 a 3 D3 0 3�� [. + 1 EH 13-24 REV. 10182 10/82 500 14-26