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APPLICATION.FO;P,PERI,;T SAN JOAOUIN LOCAL HFALTH DISTRICT 1601 F. HAZELTON .AVE., STOCKTON, CA PERMIT NO, _ _Z Telephone (209) 466-6781 DATE ISSUED I PERMIT EXPI-RES 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 Joaquin Local Health District. y. ' Job Address ' / ' g�. . �. lt. Subdivision Named S. Owner's Name ! tr Address 411 &.'r)►nj� , , Phone Contractor's Name ; License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR- ❑ OTHER ❑ r '' :DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES T OISPOSAL•FLD. PROP, LINE W FOUNDATION AGRICULTURE WELL ' OTHER'WxLL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W ❑ Industrial ❑�Open-Bottom` 0 Manteca Dia. of Well Excavation `� f l ❑� Domestic/Private ❑Gravelr Pack ❑ Tracy Dia, of Well Casing f f� Public ❑Other ❑ Delta Type of Casing V Irrigation Approx. ❑ Eastern y Depth Specifications fications Cathodic Protection p Depth of Grout Seal Geophysical OtherType of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done = Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth •Filler. Material (Below 601) (f� = TYPf OF�SfPTIC=WORK: NEWiNSfiAtLATION � =Rf�PA'lR/4flDIT-1pN— '{Na septic#ancon.seepageyp:it�perma#.tad�i_fuh.lic sewer -is available within 200 feet.) �~ Installation will serde:--Residence's ""CoinmercVal' 'Ot4-ee Number of living units: Number of bedrooms ;' Lot size AGR 1 Character of soil to a depth of 3 feet:. - ? ��_ - J Water table depth ' SEPTIC TANK Type/Mfg , Capacity No. Compartments PKG. TREATMENT PLT, �Type/Mfg Capacity; Method of Disposal 1 SEWAGE SYSTEM Distance to nearest: Well Foundation ' Property Line i. DESTRUCTION ❑ LEACHING LINE No. & Length of lines p Fr Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ -. -bepth Size -Number _ f SUMPS ❑ Distance to-nearest: Well- _- ..Foundation#,- -' Property Line DISPOSAL PONDS' �❑ _ k }` I hereby certify that I ;have prepared this application and that the work will be done in accordance with'San Joaquin county t Ordinances, state laws, -and rules"and regulations of the San Joaquin Local health District. Home owner or licensed agent's signature certifies the-f6l'lbWing:'""I'-ce"rti,fy that in the performance of the work for which this permit is issued, I sha77 not employ any person in such manner as to became 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, shall employ.persons..subject to -workman's compensation_Jaws of California." The applicant must cal ; for 11 requ red inspections. Complete drawing on reverse side. I Signed X`' ,' Title: ' Date: FOR ARTMENT USE ONLY Application Accepted by /�T-, X11 Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by- ! Date ❑ Manteca 823-7104 Final Inspection by - Date ❑ Tracyi 835-6385 Applicant - Return all copies to-, EnvironmAdf Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE OUNT DUE. AMOUNT REMITTED y RECEIVED BY. DATE PERMIT NO. �...-..,-- .INFO -.. ;' EH 13-24 Rev. 10/8z � � 10/82 14-26 !�