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APPLICATION FOR PERMIT SAN SOAQGi"1 LOCAL HE.ALTh DISTRICT rn 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 1I --f I-II Telephone (209) 466-6781 3 DATE ISSUED �—fa 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 and the Rules and Regulations of the San Joaquin Local Hea th District. 9�.r. �Pc•V tee. d� Jab Address �� 4 `u6division Name Owner's Name��j1?. /[�eG l Address _36 ✓f Phone T �T E7 Id-3 (�1 Contractor's Name License No, Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES .' • ' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE T PE OF WELL PROBLEM AREAi CONSTRUCTION SPECIFICATIONS ❑ Industrial Eropen Bottom 1-1Manteca Dia, of Well Excavation Oomestic/Private WGravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing '✓rrigation �Z G/ Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Ins tallettd by Repair Work Done ❑ Type of Pump H.P. State Work Done F 4 Well Destruction ❑ Well Diameter Sea Iing'Material (top 50') Depth I Filler Material (Below 50') f t r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is # available within 200 feet.) Installation will serve: Residence _ Commercial] ZI Other Number of living units: Number of bedroomsv4J�` Lot size Character of soil to a depth of 3 feet: : �' Water table depth SEPTIC TANK ❑ Type/Mfg � + 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation_ Property Line . DESTRUCTION i t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation els Property Line SEEPAGE PITS ❑ Depth Size _ {�Numberl SUMPS Distance to nearest: Well `Foundation , it Property Line DISPOSAL PONDS ❑ 1 -T .�r k I hereby certify that I have prepared this application and that the work'wil'l be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San boaquin 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 become subject to workmans compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "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 Cal Iifornia." 8 The applicant must call for all required inspect ons. Complete drawing on reverse side. Signed X Title: � �— Date: 1-3 FOR D PARTMENT USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Datep� ❑ Manteca 823-7104 Final Inspection by 6 _ Datep_3 ❑ Tracy 835-6385 Applicant - Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2049, Stk., CA '95201 -or— FEE ,rteFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO +5- EH 13-24 REV. 10/82i7 `` t„ C 10/82 500 J 14-26 U,i`�'_ ` +ice