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APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH. DISTRICT " 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 0 Telephone (209) 466-6781 q DATE ISSUED PERMIT EXPIRES 1 YEAR FROM D4TE 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 Rules and Regulations of the San Joac in Local Health District. J� ) &_ ' I _ „ 0 �e� )� Y1.) s Job Address / - Subdivision Name ' •`-� {/C� y Owner's Name Address Phone Contractor's Name License No. o2`Ti' Z Phone ",5'I0 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LG -G DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION_ SPECIFICATIONS Vf ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pac2k--:L--❑ Tracy Dia. of Well Casing ❑ Public W [_1 Other ❑ Delta Type of Casing V irrigation Approx, [] Eastern Specifications Cathodic Protection Depth ❑ _..Depth of Grout Seal ❑Geophysical Type of Grout U Other .�. ./ surface Seal Installed by Repair Work Done ❑ Type of--Pump H.P.- State_Work Done Well Destruc t 'on '[] Well Diameter Sealing Material (top 50') Depth -Filler Material (Below 50') fi TYPE OF SEPTIC WORK: - NEW-INSTALLATION L1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted zf public sewer is Installation will serve: Residence - Commercial _ Other m l�` .2Lc� / available within 200 feet.) Number of living units: Number of bedrooms .0144 Lot sizel�' J Character of soilto a epth of 3 feet: Water table-depth._/101 _- SEPTIC-TANK Type/Mfg / Capacity a No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Dispos'al i SEWA'GE_SYSTEMDistance to..nearest-_WLI.L _ ,[�_}._. Foundation._ ICS Property Line_ _,5 DESTRUCTION ❑ LEACHING LINE No. & Length of lines Total lepgth/size 11' FILTER BED Distance to nearest: Well F - Foundation /p Property Line y{E� SEEP •PITS Depth, Size.' Number _ sFoundatio - SUMPS U Distance to nearest: Well n Property'Line DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinfinces,ystate laws, and rules and regulations of the San Joaquin his Local Health District. - Home"owner r licensed agent's signature certifies the following: "I certify that in the performance of the work for-which t o permit is issued, I shall not employ any person in such manner as to become subject to workmank 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 applica must call or 11 required inspections. Complete drawin o reverse side, Signed X Title: Date: FOR OEPARTME USE 0 /� ❑ Stk 466-6781 App i ation Accepted by Area 5 Lodi 369-3621 Additional Comments: Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date .3 ❑ Tracy 835-6385 Applicant - Return all copies to: ro mental,Health Permit/Services 1 Olt Hazelton Ave., P.O. -Box 2009, Stk., CA 95201., 1 FEE BASE - AMOUNT DUE AMOUNT. REMITTED RECEIVED BY DATE PERMIT NO. INFO �G�_ y 41[��1 C'� ,�y_r l O O T 10/82 500 EH 13-24 REV. 10/82 14-26