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APPLICATION' FCn PERMIT SAN JOA LIN' LOCAL HFALTui C:STPICT (� 1 a �� a X984 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ��`�iTS71 Telephone (209) 456-6781 DATE ISSUED SAN JOAQUIN LOCAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH DISTRICT (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 Iin 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 (9 ti J Subdivision Name Owner's Name V �/ C Address Phone. �3 Contractor's Name ,J J License Phone TYPE OF WELL/PUMP WORK: NEW .WELL ❑ WELL REPLACEMENT F-1DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK JI SEWER LINES DISPOSAL FCD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SRECIFICATIONS F-1Industrial U OpenlBottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing , ❑ Public ❑Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth 1 Depth Df Grout Seal i ❑ Geophysical Type of Grout' II ❑Other Surface Seal ;nstalled by DD Repair-Work Done :Type of Pump _ H.P. State Work Done Welt' Destruction';❑..,.•aWell Diameters r Sealing Material (top 50') y iii Depth a Filler Material (Below 50') • TYPE OF SEPTIC WORKc� NEW INSTAL-LA7ION-❑—REPAIR/AODhTION E_]�(No- 'ptic tan4k o.rLLseepage plavailableewithin200 public fsewer is ; 1 Installation will serve: Residence Commercial Other ' Number of living units: Number of bedrooms Lat-size ` S Water table depth Character of soil to a depth of 3 feet: 11 SEPTIC TANK ❑ Type/MfgCapacity No. Compartments \. PKG.T TREATMENT PLT. Type/Mfg. ` —1;'': Capacity Method of Disposal ' sEWAGELS�STEM�J' Distance to nearest: Well Foundation Property Line DESTRUCTION LEACFi1NG'LINE '❑ �No.f& Length of lines Total length/size °,. d Property Line =41 TER�'B D'ti� '; ❑` ,',Dis:tanc�ta nearest. Well Foundation P y SEEPAGE PITS ❑ Depth i Size Number SUMPS ❑ Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS ❑ �^ 1 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 rulesfand 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 per is issued, 1 shall not employ any person in such manner as to become subject to workman compensation Taws 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." t The applicanfNust call for alp re 4d inspections. Complete drawing on reverse side. „^d Signed X Title; Date: 0 PARTMENT USE,O ff 00, Areal _ b _ E:] 5tk 466-6781 Application Accepted by ❑ Lodi 369-3621 " Additional Comments: a�e _�r Manteca 823-7104/�llq— Pit or Grout Inspection b ` Tracy 835-6385 Final Inspection by Da ❑ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 45201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO A 10/82 500 EH 13-24 REV. 10/82 14-26 ' A -