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APPLICATION FOR PERMIT SAN JOAQL'i"! LOCAL HFLTH DISTRICT II 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 1 - 30 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District'. Job Address 'L M Subdivision Name- Owner.s ame- Owner's Name OL Address Phone ( Z ^ [Contractor's NameeLAft� W*4j � PLicense No. t r6b Phone -76 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION L]1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ '� DISsTANCE TO NEAREST: SEPTIC TANK Q r� SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑Industrial ❑ Open Bottom Manteca Dia. of Well Excavation /Q 1 l0omestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing r S/�,I Public �Other �,❑ Delta Type of Casing ---• EL ' S V llrrigation Approx. # ❑Eastern Specifications 'Cathodic Protection Depth ❑; ' Depth of Grout Seal Q ; DiGeophysical ; Type of Grout � n1L)irF— =Other Surface Seal Installed by Rep,ir Work Done ❑ Type of Pump H.P. State Work Done Wel IL Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPRIVADDITION 3 (No septic tank or seepage pit permitted if public sewer is available within 2DO feet.) Installation will serve: Residence Comm erci-al Other f It r, Number of living units: Number of bedrooms Lot size xf t Gharacter of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. CoWpa'rtmen ts. PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line I DESTRUCTION w t LEACHING LINE U No. & Length of lines 'Total-•length/size -:4 ? 1 FILTER BED ❑ Distance to nearest: Well Foundation ° _ 'Property Line E_ . JS E, PIT$ ❑ Depth Size Number r $OINPS ❑ Distance to nearest: Well Foundation Property Line € '915POSAL PONDS c 4Pliiereby certify that I have prepared this application and that the work will.he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following:,"I certify that in the performance of the work for which this , P' r`.mit is' issued I shall not employ any person in such manner as' to become subject to workman compensation Iaws'of California." Contracto'r'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 emp3oy ersons subject to workma compensation laws of California." a Th applica —must 11Rfo 11 requ d inspections., •Complete n •side. Z Signed X Title: �°,i€ 1 '� Date` 1 FOR D ARTMENT USE N y Application Accepted by Area ❑ Stk 466-6781 S Additional Comments: ❑ Lodi 369-3621 3 Date a�7 �y�rManteca 823-7104 i Grout Inspection by _' Final Inspection by Date ❑ racy 835-6385 Ag licant - Return all copies to. En ,ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE EASE RM011NT DUE AMOUNT REMITTED RECEIVED BY +� DATE PERMIT{NO. i# I NFO � 3�� EH 13- REV. 10/82 I� ¢ 1 •- �� f (_� r � 10/82 5b > 14-26 Df 4� `r10 W1 Tr�x 5;-5 q rjct jf �r�` 0.1'ti Vf?DtD�P. -�-�, male., i-f- G� Geor9.P C[a4-k r`ssron 40 gr0LT1—e r