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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED ° (Complete in Triplicate) s 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 Regulationsofthe San Joaquin Local Health District. Job Address ' � 5� / ��/tsTU 5 - Subdivision Name Owner's Name _ _ / ��C�� _ Address S s Phone Contractor's Name A p FLI(; License No. P Phone ,I TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION Ci PUMP INSTALLATION SYSTEM REPAIR OTHER �] DISTANCE TO NEAREST: SEPTIC TANK SEWER`LINES DISPOSAL FLD. PROP. LINE FOUNDATION --AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA n' CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom . Manteca -tiDia. of Well Excavation U Domestic/Private 0 Gravel Pack ❑Tracy 4 bias;of Well Casing Public Other r Delta d 4V I. C1 Type of Casing i Irrigation t Approx- Eastern € Specifications Cathodic Protection 3 Depth 1 t ) Depth of Grout Seal ' In Geophysical Type of Grout �] U i_ 1 Other I 1 + ) Surface Seal Installed by k Repair Work Done E] Type of-Pump`-��_ H.P. State Work Done , v V Well Destruction U Well Diameter Sealing Material (top 50') ., — Depth Filler Material.,(Below 50') JQ..� . .TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank�or seepage pit permitted if public sewer is available within 200 feet.) j Installation will serve: Residence commercial Other ---- �rw ` Number of living units: Number of bed roams " *Lot.size F/_ �.4 y i : Y� Water.table a depth Character of soil to a de th of 3 feet: , SEPTIC TANK E] Type/Mfg Capacity, No. Compartments ~} ' Ca'Qacitl?it Method of Disposal PKG. TREATMENT PLT. [� Type/Mfg NM SEWAGE SYSTEM Distance to nearest: Well -- Foundations + Property Line DESTRUCTION ❑ ' '` i /"r—r�'�Total length/size — -- LEACHING LINE No.:: &•.Length of lines _ FILTER BED [] Distance to nearest: Well Foundatior Property Line, AGE-PATS .--s, Num —Depth. � Size Number S LJ Distance to nearest: We1.1 Foundation) Property Line DISPOSAL PONDS I hereby certify that I have prepared this applicationtand that the work will'\be-don .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 th0following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such-manner..as to,become-subject to workman'; compensation laws• of California." Contractor's hiring or sub-contracting signature certifies the following: "-lrcertify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman}s com on laws of California." The applicant must ca fo 11 re red inspections.:, Complete drawin ton verse side. Signed X Title: 1 Date: ,QT R ARTMENT-USE ONLY': fJ [J Stk 466-6781 Application Accepted by Area ^h• Lodi 369-3621 Additional Comments: Pit or Grout Inspection by € I Date Manteca 823-7104 Final Inspection by _ :Da'te, Tracy 835-6385 _ to: Environmen a Heal6'P'ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant Return all copies r' FEE BASE` AMOUNT DUE -AMOUNT REMITTED RECEIVED BY DATE ' PERMIT NO. INFO ` -/to gb—�-_ • o . - 10/82 500 f EH 13-24 REV. 10/82 {