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APPLICATIO`' FOR PE2;,1T SAN JOA.QUik LOCAL HEA,LTH.DISTRICT 1601 E. HAi_ELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED 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. Job Address cd^e &a Subdivision Name rOwner's Name V dress Contractor's Name A- ` 7_!meno Phone 94"31ti��/6 :cense No. Phone TYPE OF WELL/PUMP 14ORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P f�i►.11�� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTI ANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ OpenE BottomManteca ❑ Dia. of Well Excavation f LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Other Delta rublic rrigationType of Casing Approx. Eastern n Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal U Other Type of Grout Surface Seal Installed by Repair Work Dane ❑ Type of Pumps ,._. H.P. / �� State Work Done EPRH�c +�/r Well Destruction Well Diameter U Sealing Material (top 50') 04 e I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D (No septic tank or seepage pit permitted if public sewer is /I�tallation will serve: Residence Commercial _ Other available within 200_ feet.) Cl -----'Number of living units: J Number of bedrooms Character of soil to a depth of,3 feet: t Water table depth - Y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. T e Mf ' ❑ yP / 9 Capacity e Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation :-Property Line DESTRUCTION ❑ f LEACHING LINE ❑ No, & Length of lines ! Total— i 96�y FILTER BED ❑ Distance to nearest: Well Foundation �Property'Line f SEEPAGE"PITS ❑ Depth Size f Number # { SUMPS I L Distance to nearest; Well Foundation Prgperty>Line ; E O DISPOSAL PONDS jr { I hereby certify that I have prepared this application and that the work will ,be done in accordance with'San Joaquin county M'r ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.-* 1 } Home owner or licensed agent's signature certifies the following: "Icertify that in the performance of the work for which this permit :is issued, I shall not employ any person J7' 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'�-sub-ect to wo3kman's compensation laws of California." .The app#icant st cal for equired inspections.:. Compliete dr ing on reverse side. e� / 1 Signed 'X eTitle: ? Date: `�` j + T Application Accepted PARMENT US ONLY by Area Q� [�<tk�- . ,466-6781 Additional Comments: j ❑ Lodi � 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ---�=� L Tracy x-835-6385 Applicant = Return all copies to:1 En ronmental Health Permit/Services 1601 E. Hazelton Av#, P.O. Box 2009, Stk- CA 95201 e _FEE_. �—BASE— AMOUNT—'DUE—�. 4 ..,.,,,,AMOUNT-REMITT,ED.,"�, �REC.EIVEQ_BY DATE PERMIT NO. INFO :�..�,-- 'c' ....,,."teIs -1039 EH 13-24 `;REV. 10/82 � 4 #� R . t = 10/82 500 14-26