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APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 4,36te PERMIT EXPIRES i YEAR FROM OATS ISSUED P-2,Z +(0 ,! 0-�� }Complete in Triplicate) ' "A- ) �6-5-vf�� 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 d Regulations of the San Joaquin Local Health District, Job Address 9 L, /^ Subdivision Name J C 11 ', C P, k Owner's Name 44 I Q0Cdress one ^ y Contractor's Nam y erase No-3,6 Phone �- TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ { PUMP INSTALLATION,2�SYSTEM REPAIR ❑ OTHER ❑ OJ DISTANCE TVNEA'REST> SEP TIC-TANK Z SEWER LINES /�- +c dL.r tDISPOSA LD. PROP, LINE FOUNDATION S AGRICULTURE WELL IOTHER WELLS PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA-^t` CONSTRUCTdDN SPECIFICATIONS �! 4; ❑ Industrial (—f Open Bottom Manteca r Dia. of(Well Excavation If omestic/Private,..--._.__ .,_ _a vel Pack ❑ Tracy iy `'Dia. of�Well Casing ,051� _ � 3 _ Y ' Puhl.ic _ a """""�' Other, Delta ' Type g ❑' ❑ ❑ ` i. T e of^Casin _ Irrigation ,�'r. Approx. ❑ Eastern Specifications hodic Protection; Depth Cat ❑ ,� � � Depth of Grout Seal L-J`Geopliysica'l +f„j{� \ ""'Type of Grout EJ- Other_ �.- surface Seal Installed by /Jilj C Repair Work-9one ❑ -.Type:of Pump H.P.-�-5 --• State Work Done ,�Welal;Destruct'ion ❑ rWel,l Diameter Sealing Material (top Depth , r Fil•ler,Material •(Below 50').f -.-TYPE-OF SEPTIC-WORK: NEW•hNSTALLATIQN LI—RE-PAIR/ADD-1T-ION--j J-(•No septic tank or seepage pit permitted if public sewer is within 200 feet.) available Installation will serve: Residence Commercial Other �1, 11 Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: ; Water table depth- SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments { PKG. TREATMENT PLT. [] Type/Mfg Capacity, � Method of Disposal i SEWAGE SYSTEM Ei Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size ; FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size 'Numbed SUMPS ❑ Distance to nearest: Well Foundation, Property Line DISPOSAL PONDS ❑ i 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 become subject to workman compensation laws of California." Contractor's hiring or sub-con cting signature certifies the following: "I certify that in the performance of the work for which thiermit is issued, I shall em oy persons subject to workman's compensation laws of California." I� The app 'cant must cal f a 1 req ire inspections. Complete drawing on reverse side. Title: _ Date: FEPARXM£NT USE ONLY Applic tion Accepted by /1/I1 Area Q� ❑ 5tk 466-6781 I conal Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Mante a 823-7i0 Final Inspection by Date 1 L ❑ Tracy 835-6395 Applicant - Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY Dt 44r DAATE p PERMIT N0. INFO Q `J - ,/y1\��_. c� 0 1- ��[.(Ytd � li0 82 500 E 1 EH 13-24 REV. 10/82 r- j<