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ax } w R+ APPLICATION FOR PERMIT w SAN JOAQUIN' LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 1. Telephone (209) 466-6781 DATE ISSUED f 7 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 Ruies and Regulations of than Joaquin Local. Health District. �j Job Address 2 0p_WZR D c3. . Suvi, bdiion,Name Owner's Name ' Address E Phone y. Q A Contractor's Name �7- License No. �� Phone �-- `7 oV _ W TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION L PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK A SEWER LINES DISP05AL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE, TYPE OFWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _r ❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation. .;I '- U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public E Other L Delta Type of Casing L i Irrigation Approx. [] Eastern x i Depth Specifications Cathodic Protection Depth of Grout Seal ❑Geophysical - Type of Grout Lf Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done µ Well Destructi6n ❑ Well. Diameter ] Sealing Material (top 50') — Depth Filler Material (Below 50') (� E TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITIONX (NoFseptic tank or seepage pi't permitted if public sewer is fY I i i available within 200 feet.) Installation will serve: Residence Commercial Other + g � Number of bedrooms Number of linin units: + � Lot size Character of soilito a depth of 3.,feet: & �- '• Water table depth ISO SEPTIC TANK L �J Type/Mfg •^' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg .' ; Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION C] 0 a / Total length/size€ x LEACHING LINE No. & Length of lines FILTER BED v Distance�to nearest: Well N d Foundation fQf / Property Line - - __ SEEPAGE PITS Depth Size �iY�� Number � f SUMPS Distance f+o nearest: Well — fes— Foundation 3.,Ey L Property Line DISPOSAL PONDS ❑ I : I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulatiohs 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 issue F shall not employ any person in such manner as to become subject to workman compensation laws of California." Contractor', ing or sub-contracting si ature certifies the following: "I certify that in' the performance of the work for which this permit s ssued1 shall employ p sons subject to workman's compensation laws of California." The appy nftL44iA ions. Co to n reverse side. - . Signe Title: Date:/ "" � ARTMENT USE ONLY Application Accepted by _�. _ Area U42— � Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 j 5amp -Pit or Grout Inspection by Date Manteca 823-7104 T Final Inspection by rrolcr A, Date �' ! i L Tracy 835-6385 Applicant -. Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 1 - FEE �.__8ASE RMOUNT DUE AMOUNT REMITTED 'RECEIVED BY DATE PERMIT N0. INFO 7 g3- � EH 13-24 REV. 10/82 10/82 500 , 14-26 Q�