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APPLICATIbN FOR PERMIT SAN JOAQUIN LOCW HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781• j DATE ISSUED ill PERMIT EXPIRES 1 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 and Regulations of the San Joaquin Local Health District. Job Address J�/9'C'C /4`/Vf Subdivision Name Owner's Name jf' <. 4: Address d.� Phone �' Phone S".?3 Contractor's Name 4-Se License No. '`per ' F1%��✓ TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE-TO-NEAREST: SEPTIC TANK--*- --SEWER-LINES—^^^ ''— "" --DISPOSAL FL-la:—} �-^" pROP-^LINE FOUNDATION `-I AGRICULTURE,WELL . . OTHER,WELLi=a PITS/SUMPS INTENDED USE14 TYPE OF WELL, .s -0 ROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑Open Bottom ': ❑Manteca Dia. of Well Excavation ❑ Domestic/Priva:te ❑Gra el Pack ` ❑ Tracy Dia. of Well Casing Public Other Delta ❑ ❑ ❑ Type of Casing • ❑ Irrigation ARProx___-❑Eastern Specifications } ❑Cathodic Protection r Depth -, Depth of Grout Seal ❑Geophysical ,_,'... ❑Other - Surface Seal Installed by Repair Work Done Q= Type of Pump : H.P. State Work Done Well Destruction ❑ Well Diameter —Seal ing,Material (top 501) — Depth Filler Materia(Below 50') +°•` TYPE OF SEPTIC WORK: NEW INSTALCATION U REPAIR/ADDITION �Z (No septic tank or seepage pit permitted if public sewer'is available within 200-feet.) . i -installation will serve: Residence Commercial _ Other " , Number of living units: l Number of bedrooms Lot size 3 Character of soil to a depth of 3 feet: 1-04,-7 Water table depth f o' SEPTIC TANK ❑ Typ`e/Mfgw Capacity No. Compartments I[ PKG. TREATMENT PLT. ❑ Type/Mfg l Capacity Method of Disposal SEWAGE SYSTEM ci Distance to..nearest: Well Foundation Property Line DESTRUCTION ! 'k _.-� mac.-: --- f'1 n`g LEACHING LINE LJ No. & Length of lines Total length/size Q v�fCJ FILTER BED F,71 Distance to nearest: Well Foundation IS' Property Line SEEPAGE PITS ❑ Depth Size ' "q` Number SUMPS ❑ Distance to nearest.*6well .w. k. 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 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 fallowing: "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 applicant mus call for f-l.1. required inspections. Complete drawing on reverse side. Signed X Ti le: Date: y" k Fr D RTMENT SE ONLY I Application Accepted by-; Area _ f ❑ Stk 466-6781 -_=— ❑ Lodi 369-3621 Additional Comments: Pit or Grout Inspection 'by Date LJ Manteca 823-7104 Final Inspection by # Date ❑ Tracy 835-6385 Applicant - Return all copies to. Environmental H alth Permit/Services 16 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE - „.AMOU(NT,-REMITTED- ._--,y-.-.RECEIV.EO.BY-. �a,,,-DAT.E_„__".�..�,.PERMIT_NO... t 10/82 500 EH 13-24 REV. 10/82 l r. 14-26 _ _.1�