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i� M APPLICATION FOR PERMIT `; E h� SAN JOAQUIN LOCAL HEALTH DISTRICT f �+ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 10150 Telephone (209)-466-6781 1 DATE ISSUED aL1 I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cemplete"in Triplicate) Application is hereby made 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 ofa fan Joaquin Local Health District. a Job Address w' Subdivision Name 4 Owner's Name s Phone Contractor's me744, C.Li ense No Phone I TYPE OF WELL/PUMP WORK: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION,•❑. ° �s I, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ - 'Y " I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ��0 V � INTENDED USE jj TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing ❑ Public I{❑ Other ❑ Delta Type of Casing i4 ❑ Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection ;` Depth _ .-Depth of Grout-Seal ❑Geophysical Type of Grout ❑Other ;' Surface Seal Installed by Repair Work Done [] Typelof Pump H.P. State Work Done Well Destruction !❑ Well 'Diameter i Sealing Material (top 50'") — W Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEWih NSTALLATION [:IREPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is l I; r � ravailable within 200 feet.) Installation will serve Residence Commercial Other " Number of living units:':__._/_ Number of bedrooms - Lot size Character of soil to a depth of 3 feet: 4fater table depth SEPTIC.TANK ❑ 'i'�Type/Mfg Capacity No. Compartments -� i PKG. "TREATMENT PLT, ❑ �'�Type/Mfg ' Capacity Method Of Disposal SEWAGE SYSTEM Distance to nearest: Well` "� Foundation �"" '"` Property Line DESTRUCTION ❑ � �f i9 No. & Length of lines ? Total length/size T LEACHING LINE P 9 FILTER BED 10istance to nearest: WelFoundation- Property Line SEEPAGE PITS ' E)epth _ �Size " LNumber SUMPS ❑ Distance to nearest: Well `e Foundation Property Line DISPOSAL PONDS ❑ +' "'; 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 became subject to workman compensation laws of California." Contractor's hiring or sub-contracting signature certifieskthe fo-Ilowing•:x."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 CaIlifornia.' The applica m st c 1 all u red inspections. Complete d awing on reverse s de. Signed X Title: Date: FOE ONLY I Application Accepted by Area Q'� - ❑ Stk 466-6781 Additional Comments: % ❑ Lodi 369-3621 or 0Grout Inspection Date 3 Ll Manteca 823-7104 Pi Tracy $35-6385 Final Inspection by Date ❑ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE J:AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE .p PERMIT NO. INFO at 51O c6b �p r 10/82 500 EH 13-24 REV. 10/82 14-26 !I