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i - APPLICATION FOR PE,"Mi T �. S5N JOAQUIN LOCAL ^'.EALT� D;STRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application -is hereby-made to the San Joaquin Local Health District for a permit'toYc-onstruct 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 Ru nd Regula i ` of the San in Lo Health District. , a�Y �,(!]�� / §, Job Addr oSLS'�� V" ,$ - I - - Owner's Na Address Phone ' Contractor's Na + License No. gn Phone L114 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ t DESTRUCTION PUMP-,INSTALLATION_- -.SYSTEM iREPA•l-R jzjT - BOTHER.,L-I rN DISTANCE TO NEAREST_: SEPTIC TANK jo-O SEWER LINES } GC9-O DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE�WELL�.° "^6 OTHER-WELL PITS/SUMPS INTEN6ED U5E——TYPEOF WELL PROBLEM'AAREA_ _CC_0NSTR6CTION S'PECIFICAT'IONS `w_ (� i0, industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing �J XX``❑��Public Other Delta❑ ❑ Type of Casing F-Ilrrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth roDepth of Grout Seal , ❑Geophysical Type of Grout ❑Other Surface Seal Instby Repair Work Done El Type of Pum a11 H,P, �� State Work Done Mrs) 4 Well Destruction ❑ Well Diameter Sealing Material (top 50') _ I Depth Filler Material (Below 50') t - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (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: Dumber of bedrooms Lot size u r Characterof soil to a depth of 3 feet: Water table depth SEPTIC-TANK`t ❑ Type/Mfg Capacity - No. Compartments -w_...:w PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal ' SEWAGE SYSTEM Distance_to_near.est: Well Foundation Property Line t DESTRUCTION �- LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line .- E SEEPAGE PITS ❑ I Depth Size Number SUMPS ❑I Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in a c rdance witfi'S9n'Joa46i'n 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 1s issued, I shall not employ any person in such manner as to became subject to workman compensation laws of California." Contractor' hiring or sub-Contracting si nature certifies the following: "I certify that in the performance of the work for which this permi i issued, I shall empl pe ons sub-ect to workman' compensation laws of California." The appl nt ust cal folall req it ect s. Complet r ing,on,reverse side. 3 : r i Signed x a Title: Date � F ENT ONLY Application Accepted by Area --,__ ❑ Stk 466-6781 , Additional Comments: tZ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ~� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmkazl Health Permit/Services 1601 E. Hazeltor Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT. DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT N0. INFO ' EH 13-24 REV. 10/82 10/82 500 14-26