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4-,7f � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT d 1601 E. HA7FLTON AVE., STOCKTON, CA PERMIT NO. 0 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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.Regulat' ns of the San.inqui Local Health District. Job Addres rl u/Ib__division Name. Owner's Name Address CLQ ane c7 -/t Contractor's License No. Z Z Z Phone 3�0 p /O s` lit W 7 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I i PUMP INSTALLATION. ❑ SYSTEM-REPAIR - ❑ OTHER-U - - ^- OQ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Y FOUNDATION AGRICULTURE WELL£ \ 6THER WELL'w PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r i 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing I ❑ Public ❑ Other ❑Delta E Type of Casing Irrigation Rpprox. ❑ Eastern 4 Specifications Cathodic Protection 4 i ❑ PiOepth� fk Depth of Grout Seal t ❑Geophysical Type of. Grout (A Other 1. RrSurface Seal Installed by Repair Work Done ❑ Type of Pump HSP. State Work Done Well Destruction ❑ Well Diameter 0•Seaiing Material (top,50}• _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [y' REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is s -F - y t --•� available within 200 feet.) Installation will serve: Residence ..:Commercial Other ' I Number of living units: Number of be ohms Lot size Character of soil to a depth of 3 eet: Water table depth SEPTIC TANK LF Type/Mfg Capacity 00 No. Compartments a�Z PKG. TREATMENT PLT. ❑ Type/Mfg I Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Fod'ndationT- Property Line DESTRUCTION LEACHING LINE a No. & Length of lines -,7;,ya - Total length/size >'a FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS FP-11, Depth ,ag _ Siz'e 77 Number i SUMPS ❑ Distance to nearest: Wei 1.', foundation —fd� Property Line DISPOSAL PONYS'— 7. 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. f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this 1 permit is issued, I shall not employ any person in such manner as to become subject to workman.t 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 applicat must cal or 1 required inspections. Complete drawing on everse side. ` Signed X Title: I��f 1 ' _ Dater OR DEPARTMENT USE ONLY J 3 + F App � ation Accepted by T Area _� - ❑ 5tk 4b6-6781 Additional Comments: (( Lodi 369-3621 r ❑� Pit or Grout Inspection Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copi s to: nifronmental Health Permit/Services 1601 E,laelon Ave., P.O. Box 2009, Stk., CR 95201 FEE BASE AMOUNT DUE. AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO $ y3- _ $/ 83 83-5/S EH 13-24 REV. 10182 10182 500 _ 14-26