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f ' APPLICATION FOR PERMIT SAN JOAQU'IN LOCAL HEALTH DISTRICT 1601 E. HAZELTOTelephone AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 �- PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED _�-1'y 'gt1 (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 Joa uin Local HealtIw District. Job Address Z f- ��f / CoC /Ir ` R �•1`R.__. G . ., Lj, ubdivision Name Owner's Name Milo Addre © 6100 _ Phone Contractor's Name � 12t. 1644! License No. r - ` Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ J PUMP INSTALLATION SYSTEM REPAIR, ❑ OTHER U J DISTANCE TO NEAREST: SEPTIC TANK - 192 99'-f— ,SEWER LINES DISPOSAL FLD. Ioa .PROP. LINE ,_C FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II J Industrial ❑ Open Bottom Manteca r� ❑ Dia, of Well Excavation Domestic/Private Gravel PackT racy Dia. of Well Casing ❑ Public Other Delta ❑ Lj Irrigation Type of Casing /6d Approx. Eastern [—] Cathodic Protection Depth. . Specifications Geophysical Depth of Grout Seal L y t LJ Other Type of GroutpnJ'pN,1 Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [D (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 SEWAGE SYSTEM o�-I Distance to nearest: Well Foundation Property Line DESTRUCTION �-1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS D Depth Size Number SUMPS �� Distance to nearest: Well Foundation Property Line I 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 workmant 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 applin�st cac ]1fir ll required inspections. Complete drawing on reverse side. Signed X -/� r f Title: Date: 1 R EPARTMENT U5 ONLY -- E Application Accepted by Area Stk 466-6761 Additional Comments: 1-7Lodi369-3621 Pit or Grout Inspection by Z Date Manteca 823-7104 Final Inspection by Date 7"Ivl /u [Tracy 835-6385 Replicant - Return all copies to: 'EnvirolfriCtal Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT ND. + INFO if x-13• �0 1— -S _�� t EH 13-24 REV. 10/82 10/82 500 14-26