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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT. C ©r 17a 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. G 3- ` �II W� 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 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-AlmPr1 eRt Rd.T (yrJ frPSubdivision Name Owner's Name B nd,T 9 linson Address oPhonea42_081 q Contractor's Name License No- 371 560 Phone462-_.97 �N IN TYPE OF WELL/PUMP WORK: N��L WELL REPLACEMENT E] DESTRUCTION ❑ ) PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE+ :� _- - -- -4) 7 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom []Manteca Dia, of Well Excavation _ lo 5/8" _ mestic/Private Xt Gravel Pack Tracy Dia. of Well Casing 6 8 ❑ Public Other ❑ Delta Type of Casing1 teeJ [`I Irrigation Approx. � Eastern Specifications E]Cathodic Protection Depth Geophysical Depth of Grout Seal Bentonite, 501 Other Type of Grout Bentonite, Surface Seal Installed by C lk_ark We 11 Repair Work Dane FJ_ Type of Pump 1Sub H.P. 1 State Work Done _ install purap Well Destruction U Well Diameter Sealing Material (top 501) G� Depth Filler Material (Below 50') o� TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.) � Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth , SEPTIC TANK Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE U No. & Length of lines Total length/size FILTER BED F-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Humber SUMPS LJ Distance to nearest: Well 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 shat employ any person in such manner as to become subject to workman�compensation laws of California." Contractor's hiring or s on c igna ure certifies the following: "I certify that in the performance of the work for which this peAm d, 1] 1 erso ubject to workman's comp sation 1 sof a3i ornia." The appf re a ions. CompleteVP r d Signed > (�JA Title; Date: DEPARTMENT USE ONLY Application Accepted by Area _ , Stk 466-67 Additional Comments: E] Lodi 369-3621 Pit or Grout Inspection Date ❑ Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 88 x-78 EH 13-24 REV. 10/82 10/82 500 14-26