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� a APPLICATION FOR PERM3iT SAN JOAQUI"! LOCA! H=A.LTH DISTRICT �� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 -p DATE ISSUED 3 D s PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Tr (Complete in Triplicate) �� . �Z3—01 0 -01 d-3 Application is hereby made t6f6e San Joaquin Local Health District for a permit to construct and/or install the work herein , in compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1B62 for well/pump described. This application his made and the Rules and Regulaticns�of the San Joa qui n Local Health District, Job Addresse. Q� ,m+aa.hG�+e_.-R14t`�,�,,,s —Subdivision Name me hone Owner's Na Phone Contractor's Name License No, f TYPE OF WELL/PUMP WORK: NIS NEW WELL WELL REPLACEMENT DESTRUCTION �JN PU0 INSTALLATION ] SYSTEM REPAIR L OTHER ❑ w DISTANCE TO NEAREST: SEPTIC '11. ANK �S� SEWER LINES 1 _ DISPOSAL FLD. Q�PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE 11TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; Industrial .4 Open Bottom []Manteca Dia. of Well Excavation LJ Domestic/Private ,! Gravel Pack. E Tracy _ Dia. of Well Casing . r - T"" Public �- ~i! Other r [] Delta Type of Casing Irrigation ��' Approx. EJ Eastern Specifications Cathodic Protection Depth / / + Depth of Grout Seal Geophysical ,1 �Y 'fer Leve I Type of Grout t11f G Other Aj-Zorne'Iy c. Oe It Cm©Y(G(ir�5 W e±+✓ Surface Seal Installed by Repair Work Done Type of H.P. State Work Dane � YP h Pump — f°Fi Well Destruction U Well Diameter Sealing Material (top 50') Depth �I: Filler Material (Below 50') sewer TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L (No septic tank or seepage piavaeilableewithinu200cfeet.) is � Installation will serve: rResidence _ Commercial _ Other � Number of living units: Number of bedrooms Lot size � Water table depth 6 { Character of soil to a depth of 3 feet: SEPTIC TANK [j Type/Mfg Capacity No. Compartments Capacity Method of Disposal ` PKG. TREATMENT PLT. Type/Mfg SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U N:'o. & Length of lines Total length/size + FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number "i Foundation Property Line R SUMPS L-1 pistance to nearest: Well DISPOSAL PONDS ❑ �" I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county 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 ordinances, state laws, i in such manner as to become subject to workman's compensation laws of California-" 'hot employ any person Contractor's hiring or sub'lcontracting signature certifies the following: "I certify that in the performance of the work for which permit is issued, I shall compensation laws of California." this permit is issued, I shall employ persons subject to workman's The applic u four all e uired inspections. Complete drawing an rev rse sid f� / Signed X + Title: �(1 V At IM! 144 e: f� . I li FOR DEPARTMENT USE ONLY Stk 466-6781 Application Acceptl`d y Area i Lodi 369-3621 Additional Comments`: Manteca 823-7104 Pit or Grout Inspection by Date by 1 Date __ L Tracy 835-6385 Final Inspection Applicant - Return all f to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO p. 10/82 500 EH 13-24 REV. 10/82 f 14-26