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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT t ]/ 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. cJ '�✓(p Telephone (209) 466-6781 p� DATE ISSUED ��a PERMIT EXPIRES 1 YEAR FROM DATE 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 far sewage or No. 1862 for well/pump and the Rules and Regulat;on the San Joaquin Local Health District. Job Address Subdivision Name Owner''s Names Address Phone" Contractor's Name Jam- ,1� i- 9 INU XA1 aL� License No. Sf�;i1 CPhone (Al. 6 i TYPE OF WELL/PUMP WORK: NEW WELL EJ WELL REPLACEMENT�,.E] DESTRUCTION r � PUMP INSTALLATION SYSTEM REPAIR `i 1D OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL TOTHER WELL PITS/SUMPS INTENDZD USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom F-1 Manteca Dia, of Well Excavation U Domestic/Private Gravel Pack Tracy Dia. of Well Casing 17 Public 7-1 Other ❑ Delta Type of Casing e F71 Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical _ Type of Grout U Other 1.- -- ��-- --- jSurface Seal Installed by Repair Work Done G Type of Pump H.P. State Work Done Well Destruction [J Well Diameter Sealing Material (top 501) _ Depth Filler Material .(Below,# O') m TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION '1y.lf(No septic tank or seepage pit permitted if public sewer is �j available within 200 feet,) ' Installation will serve: Residence/� Commercial Other Number of living units: Number of bedrooms Lot size �W Character of soil to a depth of 3 feet: {� Water table depth SEPTIC TANK Fj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [� Type/Mfg Capacity Meth6d'of-M7 posal""'�'"-' SEWAGE SYSTEM Ei Distance to nearest: Well Foundation Property'Line ; DESTRUCTION . LEACHING LINE No. & Length of liiies 4 Total length/size f • FILTER BED Distance to nearest: Well Foundation Property Line -yam SEEPAGE PITS DepthSize Co._ Number SUMPS ,. LJ Distance to nearest: Well 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 workmans 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 shal lemploy persons subject to workman's compensation laws of California," The applic"nt mus ca hl or- eq ired in j c ions. Complete drawing onRreverse side. Signe I Title: ° + Date: 7M ENT USE Application Accepted by Stk 4&6-6781 Additional Comments_ Lodi 369-3621 Pit or Grout Inspectio y Date 2,1 0 Manteca 823-7104 Final Inspection by tDate I ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 160f E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 [FEE BRSE AMOUNT DUE AMOUNT REMITTED }� RECEIVED BY _r DATEPERMIT NO. NFO � �� W D '7 Z lp-0q SEH 13--2`4'r-�V:10782 -��'��-��_11� .�T��.;,..,,�,,.�.--.�...-,,....._..-.�_ „r.,... _,,..a...,:._-=- ;.�• .• 14-26 I ,�