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p r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON j AVE., STOCKTON, CA PERMIT NO., a - �o Telephone (209) 466-6781 - ij, DATE ISSUED f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s (Complete in Triplicate) i 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 E. Z. j LN Ll bF Subdivision Name Owner's Name _JiLon ALL Aj4 Address Phone887- JOf, Contractor's Name License No. Phone{�;�j -9( T __Ib Ib X TYPE OF WELL/PUMP WORK: NEW WELL D WELL REPLACEMENT DESTRUCTION EJ a PUMP INSTALLATION ❑ . SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation L bomestic/Private ' �...� []Gravel Pack ,L Tracy sa Dia. of Well Casing Public [—I Other Del to LjIrrigation Type of Casing Depth Eastern G Specifications F—ICathodic Protection ti 17 Geophysical Depth of Grout Seal LJ Other Type of Grout s Surface Sea] Installed by Repair Work Dane G Type of Pump H.P. State-Work,Done . Well Destruction F-1 Well Diameter Sealing Material. (top 501) ! Depth Filler'MAerial (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION b< (No septic tank or seepage`�pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Y Commercial I',Other Number of living units: _/_ Number of bedrooms Lot size Character of soil to a depth of 3 feet: S Water table depth 2df (j�( SEPTIC TANK Type/Mfg Capacity No. Compartments - F PKG. TREATMENT PLT. ❑ Type/Mfg ' Capacity Method.of Disposal T Distance to nearest: Well Foundation Property Line LEACHING LINE ` of Na. & Length ]fines .WSJ g rQ Total length/size ° FILTER BED Distance to.nearest: Well Foundations Property Line SEEPAGE PITS [J- Depth d Size Number SUMPS LJ 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 d 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 issued, I shall employ per ns subject to wor n's compensation laws of California." The appli t st call for 11 requir inspections. Comp] a dr on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by 11-12,0-;-.' Area D Stk 466-6781 Additional Comments: r Lodi 369-3621 4 Pit or Grout Inspection Date Manteca 823-7104 Final Inspection by Date 2 Tracy 835-6385 Applicant - Return all copies to: Envir nmenta Health Permit/Services 160 E. .H zelton Ave., P.O. Box 2009, Stk., CA' 95201 F FEE BASE AMOUNT DUEAMOUNT REMITTED *� RECEIVED BY DATE PERMIT`NO. INFO 1 f EH 13-24 REV. 10/82 14-26 10/82 500 `