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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� _ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED (p "� PERMIT EXPIRES I YEAR FROM DATE ISSUED { (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 a d ul ions f the San Joaqui Local Health District. M Job Address Subdivisibn Name 4 Owner's#Name f Address Phone Contractor's`Name License No, Phone e e3 - _ r TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM-;REPAIR', IJ; , r OTHER x DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t��} DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL yOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial ❑ Open Bottom ❑ Manteca Dia.`of Well Excavation Domes tic/Private ❑-Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public E,OtherDelta Type of Casing -Q Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection`, f;' "q� Depth Depth of Grout Seal .� ❑ Geophysical f Type of Grout ❑Other rf + Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is I i available within 200 feet.) Installation will serve: R 'de Commercial her rn Number of living units: Number of bedrooms Lot size _ C n Character of soil to'a depth of3 feet: Water table depth SEPTIC TANK Type/Mfg'' C — Capacity No. Compartments D., _- Capacity Method of Disposal PKG. TREATMENT PLT. Type/Mfg Mfg � nearest: We3.l _. _F.oundat ,on Property Line 11►��33 SEWAGE SYSTEM4, Distance to .� - _._ DESTRUCTION 'I LEACHING LINE No. & Length of lines Total length/size FILTER BED ] Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth _ s_ size �p ,}`Number SUMPS Distance to nearest:j Well Foundation r Property Line DISPOSAL PONDS ❑ T v, M ' } 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 person in such manner as to become subject to workmanK compensation laws of California." Contractor's hiring or sub-contracting signature cer`£ifies tFie fo1'lowing'? 'I"certify that in the performance of the work for which this rmit is issued, I shall employ persons subject to workman's compensation laws of California." Fs . The applic u call or all r uir in ections. Complete rowing vers �- Title: Date. Signe - ^�A T'U E ONLY /�G F D�$ E S l Application Accepted by Area PStk 466-6781 �� ) fi ' Additional Comments: Si ¢ ."�D �` 36 ❑ Lodi 0369-3621 Pit brrGrout Inspection-by !- -�- -- >' Date - y--w �� ❑ Manteca 823-7104W �` i• Trac. 835-6385 Final Inspectian,.by . Applicant - Return-,all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 Q 10/82 500 14-26