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APPLICATION FOR PERNIiT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 1862 for well/pump and the Rules and Regulations 9f the San Joaquin LocalHealthDistrict. Job Address S"'Am Ega&oXv ubdivision Name Owner's Name Address )1VV Phone 231 3 (QCI Contractor's Name License No. (,Z —� Phone 29-- �- TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t!" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRJCTION SPECIFICATIONS (� Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation c��h Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta T lJ ype of Casing Irrigation Approx. ❑ Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done Type of Pump .a _ H.P. State Work Done J. Well Destruction ❑ Well Diameter Sealing Material (top 50') ffr1r+r� Depth Filler Material (Below 50') �V TY S _,�EPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is O available within 200 feet.) O Installation wil -Residence Commercial _ Other Number of living units: T of bedrooms Lot size IM Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg acity No. Compartments PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation rty Line DESTRUCTION LEACHING LINE I_I No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to-nearest: Well Foundation 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 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, 1 shall employ persons subject to workman's compensation laws of California." The applicant ust all all required inspections. Complete draw' on reverse side. Signed Xs,T, r �� Title: Date: FOR�n AR�TMENT USE ONLY Application Accepted by + L 0/1___ Area oto ❑ Stk 466-6781 —ter Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by DateManteca 823-7104 Final Inspection by l] Date jZ Orsi ❑ Tracy 835-6385 Applicant - Return all copies o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FFEE � BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. LH 13-24 REV. 10/82 ` , Z*3 `q� 10/82 500 14-26 +�