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Jlyd APPLICATION FOP PERMIT NOV - - I OV „,, - I � SAN JOAQLi” LOCAL H-ALTH DISTRICT 1501 E. HAZELTON AVE„ STOCKTONg.ArY yy� JOA`lQuI PERMIT NO. Telephone (209) 456=6781 AL HEALTH DISTRICT DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y (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 r described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump F and the Rules and RegulatioA of the San Joaquin Local Health District. Job Address Subdivision Name Owner's Name Address Phone 7 7 Contractor's me License No. �� '�a 9 fes- Phone TYPE OF WELL/PUMP WORK: NE4l WELL ❑ WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLD. PRDP, LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS nti Excavao ' Industria 3 L Open Bottom �Manteca Dia. of Well , U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public L Others [ Delta Type of Casing L Irrigation Approx. Eastern Specifications L Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout LJ Other Surface Seal Installed by k H.p. J r� State Work Done Repair Work Done Type of Pumpca- Well Destruction U Well Diameter Sealing Material (top 50') � Depth { Filler Material (Below 501) ` TYPE OF SEPTIC WORK: NEW INSTALLATION L PAIR/ADDITION L (No septic tank or seepage pit availableed if withinu200csewer feet.) is Installation will serve: Residence _ CommercialOther Number of bedrooms Lot Tize Number of living units: I ;" Water table depth Character of soil to a depth of.3 feet: Ca aci.t. '. s No. Compartments ' SEPTIC TANK L Type/Mfg - p y PKG. TREATMENT PLT. F-1 Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM � Distanc,�to nearest: Well Foundation Property Line. DESTRUCTION LEACHING LINE L No. & Length of lines Total length/size r FILTER BED Distance to nearest: Well Foundation Property Line I SEEPAGE PITS Depth J_ Size Number SUMPS L—I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L a Joaquin county I hereby certify that 1 have prepared this application and that t he work will be done in accordance with San ordinances, state laws, and rule0 and regulations of the San,Joag- Local Health District, s Home owner or licensed agent's signature certifies the fol'lowing: I- certify that in the performance of the work for which this a permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." certifies the""fol-lowing;,-Ircertify that in the performance of the work for which Contractor's hiring or sub-contracting signature this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must tali for all required inspections. Complete drawing on reverse side. Date: - Title: Signed X .. ,,...�.-.,.......-. --..w*. `. EPARTMENTmUSE,�ONLY •y"r"".' ^"""" "�-„'-r�'.,./.'� `"' '""""”' Area (' Stk 466-6781 Application Accepted by ' `Lodi 369-3621 Additional Comments: _ L Manteca 823-7104 Pit or Grout Inspection,.by' - Dat S Final Inspection Date _ �l ❑ Tracy by 835-6385 ;.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 Applicant - Return all copie DATE PERMIT NO. FEE BASE AMOUNTItQUEO��_ AMOUNT REMITTED RECEIVE➢ BY - .- - 'INFO -- 10/82 500 JLC J EH 13-24 REV. 10/82 14-26