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�I APPLICATION FOR PERMIT 4 ;j j SAN JOAQUIN LOCAL HEALTH DISTRICT ? 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, — I, Telephone (209) 466-6781 DATE ISSUED ii PERMIT EXPIRES 1 YEAR FROM DATE ISSUED II (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump a and the Rules and Regulations of the San Joaquin Local Health District. R Job Address _ Subdivision Name Owner's Name Address 1P/,,�CU1��if/p �/ftjy Phone S 3'ys/$p Contractor's Name License No. Phone r TYPE OF WELL/PUMP WORK: II NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR j� OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE CA FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial I n Open Bottom Manteca Dia, of Well Excavation Domestic/Private 0 Gravel Pack ❑Tracy Dia, of Well Casing -- PublicType of Casing i� D Other Delta �. LjIrrigation I; Approx. E] Eastern Specifications Cathodic Protection Depth Geophysical I Depth of Grout Seal (�Other I Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction LJ We11!!Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEWIINSTALLATION LI/REPAIR/ADDITION J% (No septic tank or seepage pit permitted if public sewer is Installation will serve: �I Other Commercial Residence 1�// available within 200 feet.) _ _ Number of living units: Number of bedrooms) _ Lot size Character of soil to a depth of 3 feet: A Aobe- Water table depth SEPTIC TANK Cj liType/Mfg Capacity _J_20Q_T No. Compartments o6 PKG. TREATMENT PLT. ❑ ,Type/Mfg Capacity Method of Disposal ! �IDistance to nearest: Well r)0 F)4r Foundation Property Line Septic Tank I, __._�. LEACHING LINE U [No. & Length of lines Total length/size FILTER BED E hDistance to nearest: Well Foundation " e 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." The applicarlmust ca,4 for all required inspections. Complete drawing on reverse side. Signed X Title: Date: j� FEPARTMENT USE ONLY Application Accepted by _� , T p A-a-+ �. _Area �� E] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date LEI Manteca-823-7104 Final Inspection by _ Date --��2 L Tracy 835-6385 ' Applicant - Return all copie o: Environ ntal ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 II FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 r u