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i APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT •�' � °"°` �j7� �� 1601 E. HA7ELTON AVE., STOCKTON, C NO. O 3 Telephone (209) 466-6781 1983 GATE ISSUED -5 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete it Triplicate) � = ,3�) r? � LOCAL 0' Application is hereby made to the 5an'Joaquin Local Health District for a permit41E�� r tWS/TR1QTll 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 /off the San Joaquin Local Health District. Job Address_ ],,i� Zu -�/1-u A � ..-Subdivision Name P "� - Owner's Name / Address -11 .Zc/ -�y x ,� Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL D -WELL REPLACEMENT F DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U tf`J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL-. PROBLEM„AREA, CONSTRUCTION SPECIFICATIONS r� t - =�=:- -ma=r - - :— ndustriah �'�` ”' U-Open'B`attom" 0"'Mariteca Dia"'of`Wel"l�Excavation Domestic/Private. Gravel Pack Tracy Dia. of Well Casing L--� Public F-1 Other [] Delta Type of Casing �j Irrigation Approx. Eastern --r— Depth "'Specifications Cathodic Protection Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done Type of Pump H.P. f State Work Done ,w - Well bestruction LJ Well Diameter Sealing Material (top 501) _ c,6 , Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION j (No septic tank or seepage pit permitted if public sewer is �} available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of Diving units:y Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LERCHING.LINE U 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 Joaquir 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 for all required inspections. Complete drawing on reverse side. �} y,_ n " S b Signed X�p�;p4 "! Il[.r.,r Title: Date: 'j FgADEPARTMENT USE ONLY Application Accepted by '�-�V -__ Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by 4/ Date ❑ Tracy 835-6385 Applicant - Return all copie nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE BASEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE , PERMIT NO. l INFO EH 13-24 REV. 10/82 10/82 500 14,26