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APPLICATION FOR PER17 SAN 10AQL1% LOCAL HEALTH DISTRICT " D 3- (iA 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 7 3 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 30dquin Local Health District. Job Address O y Subdivision Name �1 Owner's Name Address �"�/ /�/ i7��.rf� _ Phone 0 Contractor's Name `J;, f� / ,s,,,� License No. ,� �� / Phone C,/�tf— W } TYPE OF WELL/PUMP 14ORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑� DISTANCE TO NEAREST: SEPTIC TANK "d SEWER LINES ,1�� _ DISPOSAL FLD. PROP, LINE �— FOUNDATION —� AGRICULTURE WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation z67 Domestic/Private 'Gravel Pack E] Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing 4"L Irrigation Approx. Eastern y Depth ❑ Specifications ❑Cathodic Protection p Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by tom! Repair Work Done ❑ Type of PumpH.P. State Work Done Well Destruction Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') , I`+~ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pi-t permitted iT`public--sewer is 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 [-j Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM c1 Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 applicant m call for al, requyred inspections. Complete drawinn.n re eside. Signed X I& ! _ Title: Date: rK ARTMUSE ONLY 1/ 1 / Applicatio ccepted y Area ?1,3�3 ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date 7��3 ❑ Manteca 823-1104 Final Inspection by Date R h-ga ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 00 EH 13-24 REV. 10/82 10/82 500 14-26