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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 ' I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HATE ISSUED (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 an d_Regull!a��tions of the San Joaquin Local Health District. Job Address FA tt O.:q •� Subdivision Name Owner's Name �,i i L .0 LeD!C� ess Phone Contractor's Name y4.,2„ otzuezeEa License No. x'26d_-!r2 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i "'DISTANCE TO-"NEAREST SEPTIC TANK"-"" LINES - 1ISP0SAL'FLb.- PpOF, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s 17 Industrial ❑ Open Bottom []Manteca Dia, of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ❑'Public ❑ Other ❑ Delta Irrigation Type of Casing U 9 Approx. ❑ Eastern Depth Specifications ❑ Cathodic ProtectionDepth of Grout Steal -- ❑Geophysical ' 1 ❑Other fJ Type.of Grout ! �n t Surface Seal Installed Repair Work Done ❑ Type of Pump H.P. State Work Done- Well Destruction ❑ Wetl Diarheter Sealing Material (tap 50') Depth Filler later,ia1'($eIow 50' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION No se tic-tank or seepage pit ermitted' if ubli sewer is CJ_ ( Pp P P �- k T ' availablelwithin 200�feet.) Q Installation will serve: Residence Commercial _ Other• ` " ! `- '11% + i ' Number of living units: �_ Number of bedrooms Lot size r Character of soil-to a depth of 3 feet: A Water table depth ! 1!1 SEPTIC TANK Type/Mfg' �. L1 Capacity No..Compartments PKG. TREATMENT{Phil, t Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM `` Distance to nearest: Well Foundation Property„Line DESTRUCTION El p LEACHING LINE No. & Length of lines �'�,�'� Total length/size ! i FILTER BED ❑ Distance to nearest: Well Ae=Pl Foundation Property Line F SEEPAGE PITS ❑ Depth Size Number SUMPS ` ❑ Distance to nearest: Well Foundation Propedly,Line DISPOSAL PONDS _ ❑ �un��ir�rri.�r�i i i i i u in■■r�rrr- i a_ i 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,Di'strit�t. Homeowner 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 lows of California." € The applicant must call r all quire inspections. Complete drawing on reverse side. 9 �. - G Si ned X A r .. .� Title: ��,i,�,it.,t% Date: " R D RTMENT USE ONLY 1 ` Application Accepted byo r Area .. �� ❑ Stk i 466-6781 r Additional Comments: ❑ Lodi 1 369-3621 Pit or Grout Inspection by Date ❑ Manteca,.823-7104 final Inspection by Date ❑ Tracys 835-6385 Applicant - Return all copies to: Environments alth Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO _.. __.n. __.T-- -. . .- _ _ -.. . ..• EH 13-24 REV. 10/82 '".10/82500_ 14-26