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I � APPLICATION' FOR PERMIT r ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON,_CA - 3�6 � PERMIT N0. Te}ephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED �~ DATE ISSUED ✓ 4av� , (Complete in Triplicate) .App]ication 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 Joaquin Local Health District. Job Addis Nas�oVh- ,!� {' / � ,� .� ^0�1 n"i Subdivision Name Owner's NameC Address .� Contractor's Nam �j Phone License No. Q y 0 ' Phone TYPE OF WELL/PUMP WORK: NEW IWELL WELL REPLACEMENT DESTRUCTIONS ' is PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. �� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS Industrial ,/Open ;Bottom Manteca ) �1 ❑ Dia. of Well Excavation ❑ Domestic/Private Gravel Pack [7j❑ Trac Y Dia. of Well Casing ❑ Public ❑ Other Delta / i t Type of Casing Irrigation Approx. Eastern le C Cathodic Protection Depth Specifications tT� Geophysical Depth of Grout Seal U I' ► i L Other �. j Type of Grout ` Surface Seal Installed by Repair Work Done L Type of Pump H.P. � State Work Done Well Destruction Well Diameter r Sealing Material (top 501) Depth Filler Material (Below 50'} Y TYPE OF SEPTIC WORK: NEW INSTALLATION LlREPAIR/ADDITION ❑ (No septic tank or-seepagepit permitted if public sewer is Installation will serve: Residence Commercial Other A available within 200 feet.) Number off living units: Number—ter oaf bedroorns """"" "' '"""'Uot,size ^`�' �" '" "'�`�^ " • ,�� -: ,„a,-0 ._ - l Character of soil to a depth of 3 feet: Wates table depth SEPTIC TANK T ❑ ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to n0earest: Well Foundation Property Line DESTRUCTION ❑ I LEACHING LINE J No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation PropertylLine SEEPAGE PITS Deptih Size Number ;►,� SUMPS L— Distance.to nearest: Well _ Foundation PropertylLine DISPOSAL PONDS LI . ;r j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county 1 ordinances, statelaws, 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 empl any person in such manner as to become subject to workman compensation laws of California." Contractor's iring or sub-contrac ing signature certifies the following: "I 'certify that in tha performance of the work for which this permi issued, I sh 1 em oy persons subject to workman's compensation laws of California,", The appli a m st call fofired inspections. Complet avring reverse s cle. J Signe Title: /�i�f. �. Date: I+ � 1� Yt PARTMENT USE ONLY Application Accepted by � Area 5tk "�"�`�.$� Additional Comments: Pit or Grout Inspectio l. Date El > [E—Lodi 369-3621 rw ;-L Manteca 823-7104 Final Inspection by Date ! / 7� Tracy 835-6385 Applicant - Return all copi to: Environmental Health Permit/Services 160 E. H zelton Ave., P€.0. Box 2009, Stk., CA 95201 7 FEE BASE AMOUNT DUES AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EW7 I .. -EH 13-24 REV. 10/82 , a ` 14-26 10/82 500 k