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APPLICATION FOn PERMIT SAID JOAQLi"� LOCAL HF!LTH C,S7RICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 3 DATE ISSUED PERMIT EXPIRES i 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�o,ft San Joaquin Local Health District. Job Address o� 1-7 fl/t bdivision Name Owner's Name ddress Z`� J 1 7 �. ' , yycr� Phone(P g"' Contractor's Name[ , r� f License No. 46 Z- 7 3 Phone , TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U I l PUMP INSTALLATION SYSTEM REPAIR OTHER IJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I J Industrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Private [] Gravel Pack ❑ Tracy Ilia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern [J Cathodic Protection Depth Specifications Depth of Grout Seal ❑ Geophysical Type of Grout U Other pp Surface Seal Installed by Repair Work Done �' Type of PumpN.P. State Work Done1"nnAzy Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments } PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal }l SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS_ ❑ Depth Size Number SUMPS ❑l Distance to nearest: Well Foundation Property'Line DISPOSAL PONDS Cj 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 perfornance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmanIs 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 applican lust all fo equired inspections, Complete dcfbqng on reverse side. Signed X 241itIe: Date: 71 D- FOR DEPARTMENT USE ONLY Application Accepted by _4,7 Area Stk 466-6781 Additional Comments: l % Lodi 369-3621 Pit or Grout Inspection D Date Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copi to: Envi onmental Health-Permit/Services 160 • L. H z� ton Ave., P.O. .Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26