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Lal APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �j 1601 E. HAZELTON AVE., STOCKTON,r CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED 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/pump and the Rules and Regulations of th San Joaquin Local Health District. Job Address - V-00 q) e�� 9d" Subdivision.Name Owner's Name G. ld- �aI d>-16 UI -P-0-5. Address _"_O LJ CkuF-Jt_SO ' cg�+� Phone Contractor's Name _060ma License No. 3 — Phone . mur iruu.ri. w TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U 1 �DI•STANCE 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 g1ndustrial U open Bottom E] Manteca Dia, of Well Excavation U Domestic/Private Gravel Pack Tracy Dia. of Well Casing ( Public Other Delta 3 Type of Casing Lj Irrigation Approx. Eastern Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal Other Type of Grout 11 � Surface Seal Inst lied by Repair Work Done Type of Pump Tk✓D�r+74 H.P. �a State Work Done �p Well Destruction ❑ Well Diameter Sealing Material (top 50') .0 . Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character. of soil to a depth of 3 feet: i�- Water table depth SEPTIC TANK El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [� Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance 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 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 workman 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." i The applicant must call for all required inspections. Complete dr in on Fevgrse e./ ` Signed X O� Title> r f r^� Date: A/ DEPARTMENT US . ONL r Application Accepted by 7�1 ,�� Area 0 {] Stk 466-6781 I Additional Comments: Lodi 369-3621 Pit or Grout Inspection by p Date LL] Manteca 823-7104 Final Inspection by Date 7j ❑ Tracy 835-6385 Applicant - Return all copies to: Env' onmental Health Permit/Services 1601 E. Hazelton Ave., P.D, Box 2009, St k., CR 95201 FEE BASE AMOUNT ;DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26