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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (2.09) 466-6781.1 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE 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 Joa Local Health District. IJ Job Address Q mq T29!�� Subdivision Name f Owner's Name °� j h, Address. Phone T p A b3 LM ON y Contractor's Name '��,}� License No. Phone 41 TYPE OF WELL/PUMP WORK: NEW WELL �]„} WELL REPLACEMENT ❑ QESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION �1, AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE':OF WELL PROBLEM AREA -3-.,^k CONSTRUCTION SPECIFICATIONS s Industrial - U Open Bottom 'F7 ❑ Manteca• ^ Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack [71 Tracy Dia, of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing F, Irrigation ApproxEastern` - —°�- ❑ Cathodic Protection Depth Specificationsx4 Geophysical of Grout Seal f Type of Grout Other Surface Seal Installed by sly Repair.Work- Dane Type of Pump H.P. State_Work.�Done Well Destruction U Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW-INSTALLATION FJ-J ,REPAIR/ADDITION K(No septic tank or seepage pit permitted if public sewer is Q available within 200 feet.) Installation will serve: Residence _ Commercial _ Other , Number of living units: Number of bedrooms Lot size ) Character of soil to a depth of.3 feet: s Water table depth _ SEPTIC TANK Cl Type/Mfg Capacity No. Compartments _ 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 L1n J Total length/size ( C) FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ® Depth 2 a Size Number ; SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ED ; 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 persoVin such manner as to become subject to workman compensation laws of California.” Contractor's ng or sub-contracting signature certifies-the following;-"-I-certify-that.in 4he•performance.-of..the work for which this permit h- ssued, I s all emplo per 6ns'subject to workman's compensation laws of California." The applica ust Ball f r all req i n pZ!,rtions. Complete drawing on reverse side. I Signed X Title: Date: FOR PARTMENT USE ONLY Application yAccpted by , Area Stk 466-6781 Additional Comments: L] Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date �i �� Tracy 835-6385 Replicant - Return all c ie o: Environmental Health Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO . .Q �-•�t— 3 3 --1�5 EH 13-24 REV. 10/82 20/82 500 14-26