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APPLICATION FOR PERMIT + SAN JOAQUIN LOCAL HEALTH DISTRICT it 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone-(209) 466-6781 , + , 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 Joaquin Local Health District. Job Address_ ��3 �:� lam ( 'Subdivision Name Owner's Name Address F �r r I -' Phone Contractor's Name 'A , Fh ��/j.; License No. Phone ' -PUMP INST`ALLATiON'pf' SYSTEM'REPAIR OTHER' TYPE OF WELL PUMP WORK: NEWWELL WELL REPLACEMENT ` , N� DESTRUCTIO DISTANCEITO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDA PROP. LINE i FOUNDATION IM AGRICULTURE WELL OTHER WELL ) PITS/SUMPS INTENDED USE TYPE'COF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Opens Bottom [] Manteca Dia. of Well Excavation U Domestic/Private Gravkel Pack ❑ Tracy Dia, of Well Casing 17 Public E]Other-- 0 Delta ----�—r� Type of Casing Lj Irrigation +Approx. _- ❑Eastern— f ions Specificat , Cathodic Protection Depth S.l ;; — Depth of Grout Seal J ❑Geophysical " ^ Type of Grout Other f ' Surface Seal Installed by Repair Work Done Type of Pump. 't;"l H.P. State Work Done i Well Destruction �y. Well Diameter ) s Sealing Material (top 501) 4{ ' Depth Filler Material (Below 501: , l TYPE OF SEPTIC WORK: NEW INSTAL-CATTION REPAIR/ADDITION fJ (No septic tank or seepage'•,pit permitted if public sewer is' �+ t-_ '• j available within 200 feet.) Q installation will serve: Res'idence Commercial _ Other. �- ,Number of living units;� Number of bedrooms Lot size Character of it to'Vdepth oik3 feet: /Q Dp 9Z5 Water table depth's / SEPTIC TANK i Type/Mfg Capacity _cam No.. Compartments PKG. TREATMENT PLT. ] Type/Mfg' Capacity Method of Disposal € SEWAGE SYSTEM rr F'�` E Distance to nearest: Well Foundation_. /,�� Property Line DESTRUCTION ❑ jj LEACHING LINEti ! No., & Lehngth. of lines ��Q Y" Total iength/size` 67 FILTER BED ; Distance to,nearest: Well Foundation Property Line SEEPAGE PITS ! ❑ Depth "i� ./ Size Number SUMPS t IJ Distance'--to nearest: Well Foundation Property Line DISPOSALIPONDS s ❑ :I:{r{ } i.ruir �wr ep I herebycertifythat 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 person in such manner as to become subject to workman 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, lishall employ persons subject to workman's compensation laws of California." The applicant must call f ai r,quired inspections. Complete drawing on reverse side. Signed XE : ," Title: Date: ; �' FOR DEPARTMENT USE ONLY Application Accepted by Area 1 ❑ Stk 466-6781 Additional Comments: IIS [] Lodi 369-3621 Pit or Grout Inspection by i P Date Manteca 823-7104 Final Inspection by dffw DateL7Tracy 835-6385 i Applicant - Return all copies to: iEnviroOUtal Health Permit/Services 1601 E. Hazelton Ave„ P:O. Box 2009, Stk., CA 95201 f _ FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO �� .._. _..�.. EH 13-24 REV. 10/82 10/82 500 14-26