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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL,HEALTH DISTRICT ff 1601 E. HAZELTON RVE.,�STOCKTON, CA PERMIT NO. Telephone -(?09) 466-6781 DATE ISSUED 7 PERMIT EXPIRES 1 YEAR FROM 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 �6 3 6 D ctS 6A<r- e Subdivision Name Owner's Name U rL(eAddress 01t0 s d <<4! IF0 a S�7 'KZ Contractor's Nameacense Na. 02 4 Phone 7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION ❑ �n PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ V DISTANCE TO NEAREST: SEPTIC TANK tSS SEWER LINES DISPOSAL FLD" /Od PROP. LINE .l FOUNDATION AGRICULTURE WELL OTHER WELL fi* PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .: 17 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' 14 Domestic/Private kGravel Pack ❑ Tracy Dia. of Well Casing 6 Public [j Other ❑ Delta Type of Casing Lj Irrigation Approx. ❑ Eastern Specifications ` 9,. Cathodic Protection . a Depth ❑ Depth of Grout Seal SD � }-- ❑Geophysical Type of Grout me'v UTow.[ ❑Other Surface, Seal Installed by A. M mos s �5, I� Repair'Work Done [ "Type of Pump - n w H.-,P " -State-Work-Done - - Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,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 ❑ Type/Mfg k Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: . Well Foundation Property.Line DESTRUCTION ❑ LEACHING LINE ❑ No. &'Length of-lines Total length/size FILTER BED ❑ Distance to nearest: . Well Foundation Property Line SEEPAGE PITS ❑ Depth ' Size Number SUMPS 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 workmans 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 st call for all required inspections. Complete drawing on reverse side, Signed X �• /C Title: WArer Date:. DEPARTMENT USE ONLY �� Applfcatio Accepted by Area _,y= Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 k E4-t-or Grout Inspection by Date t 3 ❑ Manteca 823-7104 ( Final Inspection by Date / L7 Tracy 835-6385 Applicant - Return all copies to: . Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT; DUE AMOUNT REMITTED RECEIVED-BY DATE PERMIT N0. INFO 3_ao �a 1P7 2'�' 7a--6S D f EH 13-24 REV. 10/82 10/82 500 G 14-26