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APPLICATION FOR PERMIT SAN �OAQL'IN LOCAk HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. $3 1 Telephone (209) 466-6781 6 1 S F PERMIT ERPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED lk (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 ocal Health District. ` Job Address S 941 `1>0 Name c> Owner's Name i Address Phone y_P6 f 4 Contractor's Name � �f2o EIi � f�� License No. Phone j k TYPE OF WELL/PUMP WORK:" NEW WELL [] WELL REPLACEMENT DESTRUCTION ❑ POMP INSTALLATION SYSTEM REPAIR OTHERI DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FLD. , - PROP. LINE FOUNDATION ��- AGRICULTURE WELL — ��-E OTHER WELL PITS/SUMPS � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Manteca T ❑ Dia. of Well Excavation r� Domestic/Private -.,c it t 6 Gravel Pack ❑ Tracy Dia. of Well Casing L] Public Other [] Del to F, Irrigation1 C�1 ��9L1� DO pEastern Specifications ❑ Cathodic Protection Depth Type of Casing ❑ Geophysical Depth of Grout Seal U Other Type of Grout Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done 10*1 Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth I� SEPTIC TANK E] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation DESTRUCTION ❑ n Property Line ` LEACHING LINE U No. & Length of lines -Total- length size FILTER BED Distance to nearest: Well Foundation Property'Line U SEEPAGE PITS C1 Depth Size Number 2 SUMPS ❑ Distance to nearest: Well Foundation �. Property Line DISPOSAL PONDS 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ry 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'dr sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shat employ pylons subject to workman's compensation laws of California." The applica ust al for 1 re it inspect1 ns. Complete drawing on revers 'side. Signed .X, Title: Date: } FOR DEPA TMENT USE ONLY Application Accepted by �Area �- Stk 466-6781 Additional Comments: x ❑ Lodi 369-3621 Pit or Grout Inspection by Date anteca 823-7104 ' 'Final Inspection by rVADate , �� _ 1��► /}� L Tracy 635-6365 Applicant - Return all copies to: Environmental H lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED-E RECEIVED BY DATE PERMIT NO. INFO LH 13-24 REV. 10/82 10/82 500 14-26