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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 ' DATE ISSUED S' PERMIT EXPIRES 1 YEAR FROM DATE 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 I and the Rules and Regulations of the Sar Joaquin Local Health District. Job Address2AT t,64 0 � Subdivision Name Owner's Name T �r S`t C'.«IVS _ Address .�j1 _kj Contractor's Name ,L, (p � License No. Phone TYPE OF WELL/PUMP WORK: NEWIWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 'SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK # SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ r" ❑ Industrial ❑ OpW Bottom' ❑ Manteca Dia. of Well Excavation 'F # ` ❑� Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing �. 1 Public Delta ea 3 � ❑ ❑ ❑ Type of Casing �G '•3�. i ❑j Irrigation _ ATprox.. 0 Eastern Specifications fi Cathodic Protecti ` i ❑ Uepth of Grdut Seal ; F ❑Geophysical F Type,of Grout "= LJ Other Surface Seal- Installed by' Repair Work Done ❑f Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50') _ f E 3! Depth Filler Material (Below 50'), '�_ 1 TYPE OF SEPTIC WORK:. NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage, pit permitted if public sewer is r available within 200 feet.) c Installationwill serve: Residence �'"Commercial Other ,Number of living units: �_ Number of bedrooms _ Lot size s� Character of sail to a depth of:3 feet: { t Water table depth t .� SEPTIC�=.TANK Type/Mfg Capaciity ^'�;. tJo� Compartments r_ PKG..TREATMENT PLT. Type/Mfg' Capacity )''., Method of Disposal SEWAGE SYSTEMDistance to nearest: Well . Foundation! Prdperty Line } DESTRUCTION, ❑ s LEACHING LINE ''�� No. J§ Length of lines � Total len th g /sizei FILTER BED Distance to nearest: Well rFoundaeion Property Line F SEEPAGE PITSDepth Size Number �. +s ❑ =,,. SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ y ! /:'' ; I hereby certify that I have prepared this application and that'the work will be done jn,aLordance with'San Joaquin county ordinances, state laws, and rulesjand regulations of the San Joaquin Local Health ""i'rict. 'a i Home owner or licensed agent's signature certifies the following: "I certify 1.461 in th.)performAnce of the+work for which.this permit is issued, I shalt not employ arty person in such manner as to become s:ubject"to„workman§ compensation,laws of California." Contractor's hiring or sub-contracting sign'atbre certifies the following`: "I cert4-.that in•,tlt"e,performance,of the work for which this permit is issued, I shall employ persons'subdect to workman's compensation laws of Cali forni-a." The applicant must c f 11 req fired inspeetion`s.';:Complete drawing on reverse side. Signed' X Tit,e: t Date: — � � 4 ± € F R DFPA NT USE ONLY Application Accepted',by ^_�_ti '.��J� Area U7, ❑ Stk 466-6781 Additional Comments. Y : ? ❑ Lodi 369-3621 ` -7104 Date Manteca $23 , Pit or Grout Inspection by ❑ Final Inspection by 40 Date 3 ❑ Tracy 835-6385 . - Applicant - Return all copies to:; Environme a Heal-th Permit/Services 1601 E. 'Hazelton Ave_; P..O.. Box 2009, Stk., CA 95.201 ( F.EE BASE AMOUNT DUE AMOUNT REMITTED T N':RECEIVED BY w DATE PERN.O. k INFO 10/82 500 EH 13-24 REV. 10/82 14-26 E ,