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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DIS 1641 E. HAZELTON AVE., STOCKTON, CA OCT ry ` �� "as J PERMIT N4, Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSM�I tOAQUIN LOCAL _ (Complete in Triplicate) FILALT14 DISTRICT yApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein F 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 the San Jcaquin.Loc 1. Health D'tsiict`� � Job Address I�O [� bdivFifs�on ame F �6.�6�. {��3Owner's Name oLPho a U3 ELicense No, Contractor's Name TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLAIION � SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE - �.. FOUNDATION AGRICULTURE WELL OTHER.IJELL , PITS/SUMPS " �y.�. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION%SPECIFICATIONS I f Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private L] Gravel Pack Tracy Dia. of Well Cesing •r Public 1 Other Delta s Type of Casing V Irrigation Approx. Eastern & Specifications Depth Cathodic Protection Depth o'f, Grout Seal Geophysicalr I Type of GrOut!" U Other ,,Surface Seal.Installedtlby J II'l H p, , State Work Done ► - Repair Work Done Type of Pump, .]0.G1� - Well Destruction F-1WellDiameter `> Sealing Material (top 50') i Depth _?,S ` Filler Material (Below 50') �S TYPE OF SEPTIC WORK:3' NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage piavailableewithinusewer 200cfeet.) is r i Installation will serve: Residence _ Commercial Other W. Number of living units: Number of bedrooms Lot size Water table depth Character of soil to a dept of 3 feet: . . �. Capacity `1: No Compartments SEPTIC TANK F-1Type/Mfgn +:� Capacity � Mhhod of Disposal PKG. TREATMENT PLT. Type/Mfg, + ' Property Line n SEWAGE SYSTEM Q Distance to nearest: : YJell Foundation ` DESTRUCTION - ; ( LEACHING LINE {J No. & Length of lines: Total length size FILTER BED Distance to nearestWell. Foundation Property Line Depth Size Number SEEPAGE PITS p I SUMPS L—� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �Ia i. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county I hereby certify laws, and rules and regulations of the•San�Joaquin Local.Health-Distr_ict.r; Home owner or licensed agent's signature certifies the'following: "I certify that in the performance of the work for which�this"'F "�"r ' permit ie issued, I shall not employ any person in such manner as to become subject to workmanh 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 j this permit is issued, I shall employ .persons subject to workman's compensation laws of California." G k The applicant must call fo all re ired j nsp tons. Complete drawing on 'reverse side. pate: O 3 Signed X CJ Title: ArM R PART USE ONLY Stk 466-6781 Application ccepted y r Area � � Lodi 369-3621 k Additional Comment Manteca 823-7104 ' Pit or Grout Inspection by $ Date I Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Envi+rdn a1 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, 4 INFO } (Z- `O -�� $3 �3 S r CJL_At_ 10/82 500 EH 13-24 REV. 10/82 Li 14-26