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APPLICATION FOR PERMIT Q ± SAN JOAQUIN LOCAL HEALTH DISTRICT �V 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 93 Telephone (209) 466-6781 DATE ISSUED 1 0" 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 f the San Joaquin Local Health District. S— Job Address Subdivi ion Name17 P /vlL� rc � GfO�4 Owner's Name f Address w o Phone c10 pb Contractor's Name License No. —26 2 f Phone 6 2P 7 CnN W AI TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT E] DESTRUCTION CD PUMP INSTALLATION �' SYSTEM REPAIR [� OTHER Q DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES DISPOSAL FLD>A00PROP. LINE �f0 FOUNDATION 7 6-/ AGRICULTURE WELL OTHER WELL�:j= PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ems' F-1 Industrial ❑Open Bottom Manteca Dia. of Well Excavatioptgr Domestic/Private Gravel Pack Tracy Dia. of Well Casing L7 Public ❑Other Delta Type of Casing U Irrigation Approx. Eastern Specifications Cathodic Protection Depth Geophysical Depth of Grout Seal17 _ Other Type of Grout �?/a�.o �► Surface Seal Installed by 0{J Repair Work Done Q Type of Pump =� H.P. F %7 tate Work Done Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') /n TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is V ` available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method.of Disposal Distance to nearest: Well Foundation Property'Line LEACHING LINE No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS U 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 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 laws of California."- The applica ust call for all required in pections. Complete drawing on reverse side. Signed X Title: Date: .► OR ENT USE ONLY Application Accepted by Area �7 Stk 466-6781 Additional Comments: [] Lodi 369-362.1 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by _ Date — Tracy 835-6385 Applicant Return all copies to: Environm n 1 on Health Permit/Services 1601 E. HazeltAf. 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