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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE STOCKTON, CA PERMIT NO. - CO Z)� �Z -Z 0 J � Telephone (209j,466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6Z �- I� �� 4� J'7e' �0�(Complete in Triplicate) App11c t on her�b rads to the S -laquin Vbcal 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 AS5, 3 a _R%,.Jer Subdivision Name Owner's Name Address Rhone Contractor's Name License No.(��Z o�9(,�/ _ Phone ^� I TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT E] DESTRUCTION PUMP INSTALLATION [] SYSTEM REPAIR OTHER EJ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE p ' 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 Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing 1,9 Public FJ Other [] Delta C_Jlrri ation Type of Casing [D 9 Depthx. Eastern Specifications Cathodic Protection P 17 Geophysical Depth of Grout Seal U Other Type of Grout Surface Seal.Installed by Repair Work Done FJ_ Type of Pump H.P. State Work Done - Well Destruction U Well Diameter Sealing Material (top 501) � Depth Filler Material (Below 50') O n TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION L_1 (No septic tank or seepage pit permitted if public sewer is V l 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 4 PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED M Distance to nearest: Well Foundation Property Line SEEPAGE PITS n Depth Size Number 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 shall not employ any person in such manner as to become subject to workmank 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 applica t must call for all required inspections. Complete draw"ng op reverse side. Signed X f C Title: Q/ Date: R DEPA USE ONI,yy Application Accepted by ��,/ ENT U/U E Area CJ ❑ Stk 466-6781 Additional Comments: E] Lodi 369-362.1 Pit or Grout Inspection by Date al � Manteca 823-7104 Final Inspection by Date z Tracy 835-6385 Applicant - Return all copies to: ironmental 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 EH 13-24 REV. 10/82 �_ 1 t-'E 10/82 500 s 14-26