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APPLICATION FOR PERMIT _ SAN JOAQUiN LOCAL HEALTH DISTR per} PERMIT N0. 1601 E. HAZELTON AVL, STOCKTON �C J� �7J Telephone (209) 466-6781 DATE ISSUED d !f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,. 5 IOAQUIN LOCAL (Complete in Triplicate} `'14 L--14 DISTRICT SEA €� 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 Regula ions of;the San Joa uin Local Health District, EF' ` Subdivision Name ;lob Address Address Owner's Name 3 Phone IContractor's Name License No, Phone .TYPE OF WELL/PUMP WORK: NEVJ WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑W _ PUMP INSTALLATION ❑ SYSTEM-REPAIR OTHER ❑ Vv i:DISTANCE TO-NEAREST.: SEPTIC TANK_3 SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION -AGRICULTURE WELL OTHER WELL PITS/SUMPS r-- , i INTENDED USE ! TYPE OF WELL-_ PROBLEM AREA. CONSTRUCTION SPECIFICATIONS F '.I J Industrial U Open Bottom []Manteca `�'^�'Oib"of xcava ion ~ — D "IL-1 Domestic/Private - -�❑Gravel Pack" L]Tracy .pia. of Well Casing - ❑ Public. ❑Other Delta ❑ Type of Casing V Irrigation } -'Approx. ❑Easternecifications � Depth ' ❑ Cathodic Protection ' pepDepth of Grout Seal F `e❑,Geophysical Type of Grout s, ❑Other ' 'rSurface'Seal Installed by E H.P. State Work Done`,. . !Repair Work Done ❑ Type of Pump -;Well Destruction F-1 Well Diameter Sealing Material .(top 50'}' Depth Filler Material ,(Below 50'} q TYPE OF SEPTIC WORK: NEW INSTALL ❑ REPAIR. DIT10 J fGNo septic tank or,seepage pit availableed if withinub00cfeete' is �} y Installation will serve: Residence P-1 Commercial Other s i Number of living units:!'___/ Number of bedrooms Lot size - Water table depth 1Pd Character of soil to a depth of 3 feet: ` Capacity -.�6�-� No. Compartments SEPTIC TANK ; Type/Mfg Method of Disposal E PKG. TREATMENT PLT. ❑ �,Type/Mfg Capacity SJ�1 SEWAGE GESSYSTEMON ❑ h Distance to nearest: Well 1 C Lt—Foundation J t4 Property Line 4ell— l- roes E Total length/size � Oe9 E' LEACHING LINE L� ,. No. & Length of lraz J ,q FILTER BED ❑ Property Line Distance to nearest: Well Foundations 0 ` SEEPAGE PITS Depth Size Number t ! ❑� Welea' at-ion-' ��. Pra{�ary—L'inei SUMPS :. Distance to nearest:' l DISPOSAL PONDS ❑ = €4: 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 ` ubject to workman§ compensation laws . California." permit is issued, I shall not employ any person in such manner as to become s Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of theework for which this permit is issued, I'-shall employ persons subject to workman's compensation laws of California." `€ The applicant mu call for all r fired inspections. Complete drawin on reverse side. /1 Title: Date: j Signed X i EPART ENT ONLY �t Stk 466-6781 s` Application Accepted by Area O ,Y ❑ Lodi 369-3621 Additional Comments: ❑ Manteca 823-7104 Date -J y 8 Pit or Grout Inspection by - rTracy__-835-6385 Final Inspection by .L�1- - Applicant - Return all copies to: Environmental Health Permit/Services 1601 L. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 ' PERMIT N0. @ FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY (ID�ATE � 7 f INFO � �.� JD c� � 19`'�^ �f 1 10/82 500 EH 13-24 REV. 10/82 14-26