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APPLICATION FOR PERMIT" SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone,(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM OATE'ISSUEO ' GATE 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 the,San Joaquin Local Health District. , job Address 1 ; A, PSubdivision Name., Owner's Name ZXIr Lq. Address Phone Contractor's Name n tJL License No. / Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT (] DESTRUCTION ❑ �. " """-"'""PUMP'IN5TAL't"ATIbN'❑ '- _SYSTEM-REP_MM ❑ OTHER❑ DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public I ❑Other ' ❑ Delta IrrigationApprox, Type of Casing ❑ ❑Cathodic Eastern Protection Depth Specifications Geophysical Depth of GroutGSeal ❑Other Type of Grout 11 } Sur;ace Seal Installed Repair Work�Done ❑ Type of Pump H.P. StaterWork Done f ! Well Destruction ❑ Well Diameter � Sealing Material {top 501} i i A � # Depth Filler Material (Below 50") r � TYPE OF SEPTIC WORK: NEW INSTALLATION lu REPAIR/ADDITION No se 't•ic tank or'see a e C `� LJ ( P p g pitfpermitted if public seweriis � al G ivai7able within 200 feet.} �\ 1 Installation will serve: Residence _Zrl ercial _ Other ` Number of living units: 4- Number of bedrooms K Lot size Character' of soil to a depth of 3 feet: Water table depth SEPTIC TANK . ❑ Type/Mfg Capacity ; j',.! No. ,,Compartments -j PKG. TREATMENT PLT. T e Mf i ' ❑ yR / g Capaciyty r 'Method of Disposal SEWAGE SYSTEM Distance to`nearest: Well Foundation _. Pro ert-Line DESTRUCTION ❑ f p y LEACHING LINE No. &'Length of linesAk Total lengfh'/size /, ' i ILTER BED 1 Distance to nearest: Well ' ' Foundation ,/r: 'fit Property Line SEEPAGE PITS ❑ Depth Size :Number t. _ r.SUmpS�` ❑-�Dista'nce'to nearest: Well Foundation .f Property Line. s. w: DISPOSAL PONDS - I hereby certify that I have prepared this application and th t o work'will be d6 a in accordance'with San Joaquin coup ordinances,° state laws, and rules and regulatiions of the San..-Joaqui L'iscal Health District. ii Home owner for Iicensed agent's signature certifies the fo ll owing: "I certify that In the_perfo_rmance of the work .for whicH this permit is issued, I shall not employ any person in such manner as to become subject4to•workman§ cn pensat,ign 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 persoris subject tc orkman's--n'' sation laws of California." The applicant must call for a11 required inspections. Complete drawing n reverse side. Signed X it Te';r _w�..----r . �,® i Date: ��v F�dJjjj1E MENT USE ONLY i ! Application Accepted by ' Area ❑ e }Stk , 466-6781 � t Additional Comments Y ❑ Lodi 369-3621 Pitior Grout Inspection by Date1 ❑ Manteca 823-7104 Fin�l Inspection by ' Date ❑ Tracy 835-6385 Applicant;_}.Return all copies to: Envi ental Health Permit/Services 1601 E. Ave., P.o. Box 2009, Stk., CA 9501 - } i i FEE BASE _ AMOUNT DUE AMOUNT REMITTED RECEIVED"BY r DATE PERMIT NO. INFO ----r- ---- - <,..->-: �..r� 14-26 ' . _- _� ,r.<.a .- 10/82 500 ,{.