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APPLICATION FOR PERMIT SAN JOAQL'iN LOCAL HEALTH DISTRICT " 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781- t DATE ISSUED- 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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the-San Joaquin Local Health District. k Job Address %, � 1/w1Q^i j< _� Subdivision Name Owner's Name,ajD lti1 L�LE /G X',fb.r_AddressI;FAo 6 k. �4,u„�Cr Phone Contractor`s Na-;> yiy.r-acense No, � � ,�L` J- Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U , , DISTANCE TO NEAREST: SEPTIC TANK SEWER-LTNES `- w 'QfSPOSAC FLD. t•, PROP. LINE FOUNDATION --AGRICULTURE WELL-t- {' OTHER WELL PITS/SUMPS INTENDED USE p- TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial U Open Bottom F1 Manteca Dia. of Well Excavation I U Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public ❑ Other Delta ' Type of Casing V Irrigation Approx. ❑Eastern Cathodic Protection Depth S Specifications t i Depth,of-Grout-Seal'•n ❑Geophysical ' Type of Grout } Other > ' Surface Seal Installed by Repair Work Dane [' Type of Pump H.P. --Stat'e'Work Done C Well Destruction ❑ Well Diameter Sealing Material (top 50') 'a _ Depth Filler!MAterial (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank oriseepage p A.-permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ ' Commercial _ Other Az S T R".c-f j Number of living units: Number of bedrooms -Lof size . f �•{ —Character of soil to a depth of 3 feet: s Water table depth SEPTIC TANK Type/Mfg Capacity" No.r,£ompartments PKG. TREATMENT PLT. [ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation 'Property Line DESTRUCTION ❑ i LEACHING LINE [J No.,& Length of lines Total-length/si.ze FILTER BED Distance to nearest: Well Foundation — Pro Line f r - SEEPAGE PITS CI ,Depth , Size Number SUMPS Distance to nearest: Well Foundation Property Line , i DISPOSAL PONDS ' I hereby certify that I have prepared this application and that the work will 6e done in accordance with San Joaquin county III ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 4.- 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 workmdns 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 applicaryl: must call for all required inspections. Complete drawing on reverse side, f Signed X LSr Title: Date: 12 I' F DE AR SF ON Application.Accepted b /Area Stk 466-6783 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection # Date Manteca 82.3-7104 Final Inspection by —rotDate ❑ Tracy 835-6385 t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 J