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APPLICATION FOR PERI';T SFN JOAQLiN LOCAL ii-_ALTH DISTRICT 1601 E. HAZELTON AVE.', STOCKTON, CA PERMIT N0. {p 3 Telephone (209) 466-6781 S PERMIT EAPIRES I YEAR FROM GATE ISSUED DATE ISSUED o4 (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 Fu1410%, 0tVame Owner's Name / / Address 441& Phone Contractor's Name CAI /4V-- NQ.. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES DISPOSAL FLD. 'PROP. LINE �� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l f , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS gpDomestic/Private Industrial 0 en BottomU P ❑ Manteca Dia. of Well Excavation Gravel Pack ❑ Tracy Dia, of Well Casingublic [j Other L] Delta Q Irrigation ,Crpprox, stern Type of Casing ! Pit ecifications❑Cathodic Protection Depth 5 p L] Geophysical Depth of Grout Seal �jOther(��(� Type of Grout / l f/ Surface Seal Installed by Repair Work Done ❑ Type of Pump ' H.P. State Work Done Well Destruction ❑ Well Diameter t Sealing Material (top 501) r Depth Filler Material (Below 50') REPAIR/ADDITION TYPE OF SEPTIC WORK: NEW INSTALLATION }�� No septic tank or seepage LJ ( Ppit permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet.) 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 T yp 9 Capacity Method of Disposal �\" SEWAGE SYSTEMDistance 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 ❑j Depth Size Number SJMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI 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 orsub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I sall employ persons subject to workman's compensation laws of California." The applicant t 1 r all r r pections. Complete drawi on reve a side,-�- Signed X Title: y /�/ Date: a FO ARTMENT USE ONLY Application Accepted by Area `7 d ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date `�� Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY �7 �7DATE PERMIT NO. -INFO .y- � � t�_~-• f d`� a lJ`" � O�� EH 13-24 REV. 10/82 `�011-/s bU ^`t"� 10/82 500 14-26 Z r,—f3� ii-3 s`o