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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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 of the San Joaquin Local Health District. Job Address & ' Z .r- &e-,, �'1 Subdivision Name 910"Owner's Name ,�. yy,,��' - Address �' � Phone Contractor's Name-�d oLicense No. 7. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONjJ j PUMP,,-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ( J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel)Pack ❑ Tracy Dia. of Well Casing Public ❑ Other D Delta Type of Casing r ❑ Irrigation Approx. ❑ Eastern Depth Specifications ❑Cathodic Protection Depth of Grout Seal ❑ Geophysical- Type of Grout ❑Other a4 Surface Seal"Installed by r Repair Work. Done ❑ Type of Pump s h.P. State Work Done } t� Well Destruction ❑ Well Diameter Sealing Material {top 50`} 14 Depth t Filler Material {Below 50'} TYPE.OF-SEPTIC WORK NEW INSTALLATION-- (No-sept-ic-tank-or seepage' permitted i'f publ'ic ewer`i"s "� available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: 4 Number of bedrooms T Lot size l� {� Character of soil to a depth of 3 feet: Wate^r� table depth 1�1 SEPTIC TANK ❑ Type/Mfg Capacity Note' Compartments` ' 1i PKG. TREATMENT PLT. ❑ Type/Mfg Capacity- Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ ' LEACHING LINE No. & Length of,lines .• !Total length/size T ' FILTER BED ❑ Distance to nearest: Well`" Foundation Property Line SEEPAGE PITS ❑ Depth %,Size Number s ' SUMPS Lj Distance to nearest: Well, Foundation* Property,Line DISPOSAL PONDS ❑ F % I hereby certify that I have prepared this application and that thelwork'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 thg�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 perforinance.of:the work for which this permit is issued, I shall employ persons subject to workman's compensation laws'df California." The applicant must ca-V for all��re 'red inspections. Complete drawing on reverse side: Signed X �s 3 , _ �•••� _ Title: Dateov �- FOR DEPARTMENT USE ONLY T Application Accepted by -Area 1 ❑ Stk 466-6781 Additional Comments: '` f ❑ Lodi 369-3621 Pit or Grout Inspection by - DateManteca 823-7104 Final Inspection by { r Date Atl 0' :Tracy 835-6385 Applicant - Return all copies t Environmenta,.Health Permit/Services 1601 E. Hazelton+Ave., P.O. Box 2009, Stk., CA 95201 -- I FEE BASF" M _, RMOUNT DUF AMOUNT REMITTED RECEIVED BY DATE v, .£ PERMIT N0. 4 INFO - F - - •��_ LA 45; EH 13-24 REV. 10/82 10/82 500 14-26 vim,