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f �p +%., no,; F z �/1 APPLICATION FOR PERMIT q � SAN JOAQUIN LOCAL HEALTH DISTRRT g3' 1 1933 1601 E. HAZELTON AVE., STOCKTON, CA _ PERMIT N0. Telephone (209) 466-6781rF`OVIN L�VA1 DATE ISSUED l� PERMIT EXPIRES 1 YEAR FROM DATE ISS f DISI (�C r (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 t e San Joaquin Lo al Health District. Jab Address 14 70 L l Subdivision Name yy4 Owner's Name Address �i Phone Contractor's Name ` License No. �A t)Q()Ain _ Phone TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION —'4—P1iMP`INSTACLATI0N -SYSTEM:REPAIR-- "' OTHER U DISTANCE 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 17 Industrial ❑ Open Bottom ❑Manteca Dia, of Well Excavation t Domestic/Private Gravel Pack [] Tracy Dia. of Well Casing ❑ Public ❑ Other Delta Type of Casing Irrigation Approx. F] Eastern Specifications ( Cathodic Protection Depth ❑ Depth of Grout Seal ❑Geophysical Type of Grout ❑Other 1 Surface Seal Installed by H.P. State Work Done Repair Work Done Type of Pump (}L�,� Well Destruction ❑ Well Diameter Sealing Material (tap 50') _ Depth Filler Material (Below 50') - 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 - I �.�e�-may _:. 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 Capacity No. Compartments f 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 k DISPOSAL PONDS I hereby certify that 1 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 fallowing: "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." t The applicant g>t�e call f e ireds etti Complete draws on reverse side. Signed X 6 Y . ` jQJ If -P) _ Date: + T E ONLY Area .® LJ Stk 466-6781 . Application Accepted y Additional Comments Lodi 369-3621 Pit or Grout Inspection by Manteca 823-7104 � Tracy 835-6385 Final Inspection by Date � ^ F Applicant - Return all c to to: . Environmenta Health Permit/Services 1601 E. Hazelton Ave., P,D. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO f EH 13-24 REV. 10/82 10/82 506 14-26