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} APPLICATION FOR PERMIT V� SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. +J Telephone (209) 466-6781 '7 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 Ref�uItions of the San Joaquin Local Health strict. Job Address /" �/L' J4' ubdivision Name Owner's Name I►/ A�u Address /Z tj'/fie j.V�� j+�'fjAyf4 Phone Contractor's Name ,�-�.� d=7VL j_� License No. ;sem 1a ._. Phone 3 /-,43 TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPkTR OTHER �J DISTANCE TO NEAREST: SEPTIC TANK SEWER LVES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WEL ` OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Tracy, Dia. of Well' Casing i Public F-1 Other EJ Delta Type of Casing Irrigation Approx. EJ Eastern Depth i Specifications ❑ Cathodic Protection p Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work done` Well Destruction U Well Diameter Sealing Material'(top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION (No septic tank or seepage pit permitted if public sewer is ^� available within 200 feet.) Installation wi-11 serve: Residence Commercial Other Number of living units: _ Number of bedrooms _ Lotsize / Character of soil to a depth of 3 feet: xi ;E..r,� Water table depth SEPTIC TANK Type/Mfg P`r 1•.� TT Capacity % No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ci Distance to nearest: Well Foundation Property Line DESTRUCTION ' LEACHING LINE 19 No.'& Length of lines Total length/size _ FILTER BED ❑ Distance to nearest: Well & 4- Foundation Property Line SEEPAGE PITS ❑ Depth Size Number ! SUMPS Cl 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 must call or requir d inspections. Complete drawing on reverse side. Signed X �c Title: ,'-y�L?_� Dater r �1� OR DEPARTMENT USE ONLY / Application Accepted by Area EJ Stk 466-6781 Additional Comments: 0 Lodi 369-3621 Pit or Grout Inspection by _ Date Manteca 823-7104 Final Inspection by g Date 'Z, Tracy 835-6385 Applicant - Return all copie o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED EIVED BY DATE PERMIT NO. REC INFO z- �` -l�� EH 13-24 REV. 10/82 10/82 500 14-26