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�. 4. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH D15�RICf LNY�a 1601 F. HAZELTON AVE., STOCKTON, CA ' � � �� PERh1IT NO. Telephore (209) 466-6181 DATE ISSUED JA 10 95 PERMIT EXPIRES 1 YEAR FROM DATE [Sfi1JE.D; LCCvCAL ��f � + (Complete in Triplicate) li:V'T ` TIR,197 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 madein p i1ge_wi�h San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of th a i W Health District. / Job Address �go pL, S_uhda� Name CR , !:�'53& Owner's Name ' Address '3 Z Phore�/k-�,y /— �Q� Contractor's Name Qg p2jLicense No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ CJ-} DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IndustrialCf ❑ Open Bottom ❑ 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 Depth of Grout Seal ❑Geophysical Type of Grout Other ` Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done LA to6e"w4t.� QJ Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j� (No septic tank or seepage pit permitted if public sewer is (T1 - available within 200 feet.) Installation will serve: Residence _ Commercial _ Other • 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 f n SEWAGE SYSTEM 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 Number SUMPS ❑l 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 3 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, I shall employ persons subject to workman's compensation laws of California." The applicant u t c for all required inspections. Complete dr ng on reverse side. Signed X Title: r Date. OR DE RTMENT USE ONLY Application Accepted by Area _ _ ❑ Stk 465-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date jA, Manteca 823-7104 Final Inspection by Date /W ❑ Tracy 835-63B5 Applicant - Return all copies vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 3 B3 - 3S� EH 13-24 REV. 10/82 10/82 500 14-26