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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA • 'PERMIT NO. y` Telephone (209) 466-6781 " DATE ISSUED 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 Y 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 Address 4 C- 00&_ f/E _5ffMtdivision Name " Owner's Name 3-o6- Address Phone Contractor's Name Vp 0License No. y r G Phone - TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION, ] -,, PUMP INSTALLATION ❑ ' SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL`S- OTHER WELL P175/SUMPS- INTENDED FUSE" , TYPE OF WrL"I • PROBLEM AREA i CONSTRUCTION, P�IFIGA. ONS l❑ Industrial E]-Open Bottom Ej Manteca + "w D 4. at'WeA-Excavati6n, ❑ Domestic/Private ❑Gravel ,Pack ❑ Tracy I Dia. of Well Casing �} _ t Public Other Delta.. ❑ ❑ , ❑ Type.%Qf-:. Casing Irrigation Approx. ❑ Eastern SRecif^icafions _: Cathodic Protection [DDepth 47Depth of Grout Sea] — Geo physicalTYPe of Grout. *4 ❑Other w ,_,,, yrface.Sea_l .Installed by •' rri� " Repair Work Done ❑ , Type of Pump H.P, State WoK Done Well Destruction LJ Well Diameter Sealing Material' (top 509• Depth Filler Material {Below`50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDJT.ION•, .(No septic tarWk,or seepage pit permitted ifrpublic sewer is available within 200 feet..) i Installation will serve:, Residence ✓ Commercial Other n' Number of living units: f.: Number.of_',bedrooms•. 7f Lot size Charager.of soil-to ajdeptli,of 3 feet:;, 'L Water table depth`.' SEPTIC TANK ❑ , 'Type/Mfg Y './!r i Capacity No. Compartments ar, PKG. TREATMENT PLT: ❑ Type/Mfg � l Capacity Method of'DisposaTl:�l,: ' i d Septiet Tank Distance to nearest: Well d Foundation Property Line? '" r Destruction LEACHING LINE ❑ . No. .&,Length of lines 1iJ 6 Total length/size .1i FILTER BED ❑ Distance•to nearest: Well Foundation = Property Line SEEPAGE PITS DepthZ Siie. �x Number SUMPS ❑ Distance to nearest: Well Al ' Foundation >0 Property 'Eine DISPOSAL PONDS i I hereby certify that I have prepared this application and that'the workwill be done^an accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local'Healt.h District. Home owner or licensed agent's signature certifies the following: "i j__1rtl-fy thati.iii,'the'perfo'Rance of the work for which this permit'is issued,. I shall not employ any person in such manner as to ecorme subj2ct'to workm"an `.compensation laws of California. ' Contractor's hiring or sub-contracting .signature certifies the following: "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 California." The applicant must c ll for all required.inspections. Complete drawing on reverse side. Signed X Title: Date: G FOR DEPARTMENT USE ONLY tr r Application Accepted by Area Stk 466-6781 Additional Comments: 85 Lodi 369-3621 =Pit or Grout Inspection by Date ❑ Manteca 823-7104 final Inspection by ;Date ) Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952D1 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO } 10/82 500 EH 13-24 REV. 10/82 14-26