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APPLICATION FOR PERMIT SRN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTDN AVE., STOCKTON, CA PERMIT NO. Telephone (209).466-6781 , J� DATE ISSUED I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application`-is hereby'made to the San ]oaquin 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 RulesAand Regulations of the San Joaquin Local Health District. x Job Address r�5 gj �.; G al Subdivision Name Owner's Name r Address.2 -7/ Contractor's Name lfL License No. ��BZ�� _ Phone TYPE OF WELL/PUMP'WMK —NUJ-1dELL—E] " WEL1 REPL`ACEMENT""'Q'"" ' DESTRUCTION'S ..PUMP INSTALLATION ❑ SYSTEM-REPAIR LJ OTHER CJ- DISTANCE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS i Industrial a Open Bottom Manteca ..� Dia, of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia.of'.Well Casing 1-1 Public [-1 Other Delta T Lj Irrigation Approx. E] Eastern YCasing Depth Specifications -� Cathodic Protection Depth of Grout Seal i Geophysical p 1 Type of Grout U Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ '1 Depth Fi11er Material;(Below 50'} Z TYPE:OF SEPTIC WORK: NEW INSTALLATIONP5AN/ADDITION U}(No septic tank oor se�age pit permittedif public sewer is vai within 200 feet,)Installation will serve: Residence _ ommerci'al _—Other r Number of living units: Number of bedrooms Lot size �LiQCf�� f Character of soil to depth of Y3 feet: -N��dr 6 � Water table depth /,PC SEPTIC TANK Type/Mfg Ctl+-C CapacityJr&o4 No. Compartments PKG.,,JREATMENT- PLT. [] Type/Mfg y 1 -`—CapacTty- .-" Method of Disposal SEWAGE SYSTEM II�--� Distance to nearest: -Well+ Foundation .__-f G Property Line DESTRUCTION l ' LEACHING LINE No. & Length of linesy �j -_��_ Total length/size Q FILTER BED ❑ Distance to nearest: Well Foundation ion 1 C� - Property Line SEEPAGE PITS EK Depth Size Number SUMPS U Distance to nearest: Well ( Foundation (� Property Line DISPOSAL PONDS w 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 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, I shall employ persons subject to workman's compensation laws of California." The applican � t call fo all equ�ed inspections. Complete drawing on reverse side. ` Signed X Title- Date: o �� DEPARTMENT USE ONLY Application Accepted b Area - E] Stk 466-6781 Additional Comments: ` Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ,y` Tracy 835-63$5 Applicant - Return all copies to: Environmental He th Permit/Services 1601 E. A%O, P.Q. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO f EH 13-24 REV. 10/82 10/82 500 14-26 t