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� € ff APPLICATION FOR PERMIT r = SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 i DATE .ISSUEDWN:?3� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) is Application is hereby made to the San Joaquin Local Health District for a permit tp construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinanbe No..549 for sewage or No. 1862 for well/pump " and the Rules and Regulations of the San Joaquin Local Health-District. Job Address I�S ,�5CO4�' Subdivision Name Owner's Name Address �� % fjLQ /f Phone s9� Contractor's Name ��_ �� -Cj. License No. _ � sL�a� Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ; _ PUMP INSTALLATION ❑ SYSTEM RE-PAIR ❑ ��OTHER ❑ r , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE vJ FOUNDATION AGRICULTURE WELL OTHER WELL PITS%SUMPS , I4NTENDED USE TYPE OF WELL 4 PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 {. ❑ Ind'ustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation F-1Dorestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing O Public Delta i ❑ Pub, ❑1 Other ❑ Type of Casing '1 Irrigation Approx. ❑ Eastern Specifications 71Cathodic Protection Depth Depth of Gro I ut Seal Geophysical Type of Grout �+ Other Surface Seal InstallbyY c-- Sf Repair Work Done ❑ Type of Pump H.P. .""" State Work pDone % Well Destruction ❑ Well Diameter Sealing Material (top 50') !II Depth Filler Material (Below 50') r: 4 G. = STYPE OF�5EPT3C~WORK;�iJEW-iNSS.ALLATI-ON � RE�A=I:R/SI30 TION J-; (No septic_tanY9or see{�age➢p permitted i.f public sewer is� -- :a ; g avaal,able wii hi•n 200 feet )_r;i -:_ } Installation will serve: Residence Commercial �j Other Ii ' t Number of bedrooms �'f1 Number of.living units: Lot size:.:. p� ' r •".. " * f f= (� Water table depth 106 Character of sdil: to a de th of.3 feet:,____ ,6.RdI�,Li SEPTIC TANK Type/Mfg L/ —T r% i Capacity f No. Compartments R PKG. TREATMENT PLT.,''; ,,Type/Mfg 'r; t Ca*p�city i! Method of Disposal .` SEWAGE SYSTEM Distance to nearest: Well Li Foundation Property Line DESTRUCTION ❑> l en LEACHING LINE � No. & Length o£rlines` Total lthsize d� _� �� 9 / � i<0 FILTER BED ❑ Distance to nearest: Well `Foundation Property Line SEEPAGE PITS ❑ Depth -+ °: " Size ` Number . SUMPS "°` ❑� Distance ton:'rest: Wel l - {Foundation Property Line DISPOSAL PONDS' ❑" "" _ _ } { I hereby certify that I have prepared this applicatio.n,and that,the work will bel[done in accordance with San Joaquin county ordinances,-state laws, and rules and regulations of the SanJoaquin 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 subje"c0 to workmans 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 A cal f� 1; I•equ', inspections. Complete drawing on revere side, i ��_ Signed X e. ' �.� °Title: e"��°' Date: F R DEPARTME T„USE ONLY ” Area Stk ❑� 466-6781 Application Accepted by '---- Additional Comments: �c :I ❑ Lodi 369-3621 Pit or Grout Inspection by Date u. � ❑ Manteca 823-7104 ( Final Inspection by MLALA- Date-297a O ❑;Tracy 835-6385 APpIicant - Return all copiess to: nmen HealtV Iter'mityn r`vices 1601, E. Hazelton Ave., P..O.\Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED i RECEIVED BY� DATE PERMIT NO. INFO 1iyr; 10/82 500 }, EH 13-24 REV. 10/82 } 14-26 1i s,