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APPLICATION FOR PERMIT �. q SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 L. HAZELTON AVE., STOCKTON, CA PERMIT NO. p J ✓`E' 1 n� _k I' Telephone (209) 466-6781 SU __DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE SUED -`�"' (Complete in Triplicate)} Application is hereby made to the San Joaquin Local Health District4 for a permit to construct and/or install the workherein 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 ,Local Health-District. Job Address C? �a-Subdivision Name ":Owner-'s Name; Address' Phone _r `� - �f Cont-ractorts4, of Ch License No. 2 2�(.a • �; _ �• � Phone TYPE=OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT F] DESTRUCTION v' `# '_KM' PUMP INSTALLATION SYSTEM REPAIR„ �, OTHER DISTANCE TO NEAREST: SEPTIC TANK —, (" SEWER LINES _ DISPOSAL FLb. PROP. LINE CIA FOUNDATION AGRICULTURE WELL s OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 17 Industrial Open Bottom Manteca ;-'"Dia, of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public �Other E] Delta / f Type of Casing Irrigation Approx. [:] Eastern Cathodic Protection Depth Specifications Geophysicalj �" Depth of Grout Seal Other ; f Type of Grout i` r Surface Seal Installed by -I Repair Work Done �-� Type of Pum H, , � YP p P. State Work Done We11Destruction U Well Diameter Sealing Material (top 50') { Depth i '-iller Material (Below 501) !TYPE OF SEPTIC WORK: NEW INSTALLATION U:,.REPAI DDITION (No septic tank or seepage pit permitted if public sewer is InsA at,ion wil is(3rve 2 krsi,dencefCommercial _ Other available within 200 feet.) :, �sNumber of living units}'k =. . ;Nf b rooms _ Lot size Character of soil=to a depth_of 3 feet.:` Water table depth - / SEPTIC'7RNK Cj Type/Mfg �`r .�, CapaE tyl No. Compartments ` l PKG. TREATME PLT. � �] Type/Mfg ��-� Capacity, . Method_ of Disposal ' 'Distance to nearest: Well Foundation Property Line ,LEACHING LIAE Fs-r No, & Length of lines / �- ' WB ) _ ��, Total length/size 0 Ya FILLER BE ,Distance to nearest: Well ,S Q Foundation _ (> Property Line 1f SEEPAGE RTS ❑ 'Depth Size _ Number i SUMPS Ek-f- Di stance, to nearest: Well _ Foundation' /(j� 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 f 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 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 applican ;must cal fo all required inspections. Complete drawing an veyy�e side. Signed X Title: i/ / Date:f d p FOR DEPARTMENT USE ONLY k 1. Applic ion Accepted by Area 0 Stk 466-6781 Additional Comments: odi 369-362.1 Pit or Grout Inspection b Date Manteca 823-7104 Final inspection byLv ,. Date Tracy 835.6385 Applicant - Return all copies o: Environ ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. I INFO s 17 3-36�, 7 EH 13-24 - REV. 10/82 t 14-26 10/82 500