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x APPLICATION FOR PERMIT JLIN 15 13$3 SANjOAQUiN LOCAL HEALTH DISTRICT � �Q �[ 1641 E. HAZELTDN AVE., STUCKTON, CA PERMIT NO. 0 3-', C Z) AN JOAQUIN LOCAL Telephone (209) 466-6781 DATE ISSUED HEALTH DISTRICT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- -� 1 43a (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 Regulations of the San Joaquin L ca Health District. Job Address 1 t Wf6 �� . i Subdivision Name Owner's Name . ,.-Address i )1,g Phone ' ~'.G� Contractor's Name e -Td License No. -7'90 Phone TYPE OF- WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION k PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS., ^� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �4 ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta T irrigation Type of Casing LJ g Approx. ❑ Eastern Cathodic Protection Depth Specifications Depth of Grout Seal 17 Geophysical w -Other Type of Grout Surface Seal Inst led by Repair Work Done Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') s J -_(� 1TYPE OF SEPTIC WORK: 'NEW.INSTALLATION REPAIR/ADDITION F-1 (Noseptic tank or seepage pit permitted if public sewer is r available within-200 feet.) Installation will serve: Residence _ Commercial Other IE Number of living units: Number of bedrooms Lot size Character of .soil to a depth of 3 feet: Water table depth / n SEPTIC TANK- ❑ Type/Mfg 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 v No. & Length of lines °^ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line , SEEPAGE PITS 71 Depth Size Number f 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 became subject to workmans compensation taws 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 must allf al equired inspections. Complete drawing on reverse side. Signed X Title: .i.y.c /' Date: F RIME&,E ONLY Application Accept by Area ❑ Stk 466-6781 Additional Commen s: ❑4 Lodi 369-3621 Pit or Grout Inspection bi Date Manteca 823-7104 Final Inspection by iA Date Tracy- 835-6385 Applicant - Return all copies to. Environmental_>_111h Permit/Services 1601�E. Haon,Ave., P.O. Box 20o9, Stk., CA 95201 i FEE BASE .AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0, INFO L4Mg - S " - 1S _U �3-S((0i . EH 13-24 REV. 10/82 10/82 500 14-26