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APPLICATION FOR.PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON" CA PERMIT NO. Telephone (209)466-6781 ? DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) F Application is hereby made to the Sari 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. 1852forwell/pump and the Rules and Regulationsof t San Joaquin Local Health District. Job Address 0 r Subdivision Name Owner's Name Address /vPhone - 'L Contractor's Name License No. UT,�f / Phone r TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ p� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS OJ IJ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well t Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well -Casing ❑ Public E] Other ❑ Delta x, " Type of Casing" Irrigation 4Approx. ❑ Eastern Specifications ', Cathodic Protection Depth ❑ Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by ' Repair Work Done [r Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Materialk(top 50') Depth tet- k ^Filler Material (Below 50') O ATYPE OF SEPTIC WORK: NEW INSTALLATION E&4---REPAIR/ADDITION C (,No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence ��Commercial . Other T eiavailable within 200 feet.) _ I Number of living units: —L—l. Number of bedrooms "Lot size Character of soil to a depth of3 feet: '` ~ " ,k Water table depth f SEPTIC TANK LT Type/Mfg _ -. 4a ;`-- Capacity j�+!e'1 No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity ~ "° Method of Disposal SEWAGE SYSTEM Distance to nearest: Wel'1 ' �� Foundation .wP.ropefty Lined DESTRUCTION LEACHING LINE Rol- No. & Length of lines Total length size% FILTER BED �� Distance to nearest: Well . Foundation �[�� Property. Line � f SEEPAGE PITSDepth c��!. Size _f Number SUMPS L Distance to nearest: Well Foundation �� Property Line DISPOSAL PONDS ❑I ;' 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 workmang 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 mu all fo a aired inspections. Complete drawing on reverse side. Date: O Signed X� Title: _ -- � �- FOR DEPARTMENT USE 0 LY Application Accepted by - - Area -_ -:- Q---Stk-466-6781 Additional Comments: L 1 .E Lodi 369-3621 Pit or Grout Inspection by 17 Date �f Manteca 823-7104 Final Inspection by JC4, Date ✓ 0— Tracy 835-6385 Applicant - Return all copto::.. Environmental alth Permit/Services.,1.601 E. Haze ton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ` ��-f t -v -93 W y EH 13-24 REV. 10/82 10/82 500 14-26