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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 'Z IA—y n Telephone (209) 466-6781 , I 7—� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED L (Complete in-Triplicate) Application is hereby made to the Sar, 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 H 1th. District. Job AddresX Subdivision Name Owner's Name l'lwe v Address� � k Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW.,WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCt TO NEAREST: SEPTIC TANKi. SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USEJ J TYPE OF WELL: PROBLEM AREA CONSTRUCTION SPECIFICATIONS JJ Industrial U Open Bottom Manteca- Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack Tracy" Dia. of Well Casing ❑ Public ❑ Other Delta.- Type of Casing F, Irrigation Approx. ❑ Eastern Depth Specifications ❑Cathodic Protection v p ❑Geophysical Depth of Grout Seal r J Type of Grout U Other _ Surface Seal Installed by [�' � � k Repair Work Done;p Type of Pump* �� H.P M r State Work Done .� ' — Well Destructid'n ❑ Well Diameter 5ealang Material (top 50') .� Depth. ti= • Filler Material (Below 50') fif ICY I 1 YI I IO�Y I��i� -iIIIIYAi�YY� � F TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION U (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 I: Character of soil to a depth of 3 feet: Water table depth 0 SEPTIC TANK Type/Mfg Capacity No. Compartments � PKG. TREATMENT PLT. Type/Mfg '' Capacity' Method of Disposal 0 SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION Cl LEACHING LINE ❑ No. & Length of lines Totaf length/size FILTER BED Distance to. nearest: Well Foundation Property Line SEEPAGE PITS F—j Depth Size _ Number SUMPS Ll 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 fnr which this permit is issued, I shall not employ any person in such manner as to become-subject to workmant 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 must call or a qui d in�p tions. Complete dra g on reverse side_. Signed X r Title: Date: ORPARTMENT USE ONLY Application Accepted by F' t Area 07 . Stk 466-6781 Additional Comments: C] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: . Envi onmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .t FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. r INFO t 77 EH 13-24 REV. 10/82 10/82 500 14-26