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APPLICATION FOR PERMIT- SAN ERMITSAN 20AQUiN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT NO. PERMIT EXPIRES I YEAR FROM DATE ISSUED 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 aquin Local Health District. Job Address 12 7_76 S FLO— Subdivision Name f Owner's Name Address 7a { Contractor's Name , y Phone a License No. Phone f TYPE QF'WELL/PUMP 41flRK: 'NEL! (JELL` "❑ WELL REPLACEMENT RESTRICTION-C { PUMP`-I-NS-TAL-L-ATIDN ❑ t - ❑ SYSTEM REPAIR,. . ❑_ OTHER -U _.�..:`' 4 t DY STANCE TO SEPTle TANG . SEWER LINE$ DISPOSAL FCD. . ` PROP. LINE t' rYw. - •,•` .'TFOUNDATION AGRICULTURE WELL !: OTHER WELL PITS/SUMPS r INTENDED USE y s TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS' — - I J Industrial . . +M , U Open Bottom ❑Manteca Oia, of We,11 Excavation + t - -- (J Domestic/Rr�.ya'te, Q Grevel'Pack Trac r- v ❑ y Dia, of'Gell "Casing __ ❑ Public >. , Other.�l4 Delta 1 P i Lj Irrigation ' "'i 1� 1 ❑ Type of;Casino Approx. Eastern Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal ❑Other, . Type of Grout t Surface Seal Installed by i Repair Work Done Type of PumpH.P. State,Work Done i Well Destruction U Well Diameter Sealing Material (top 50') 9! A J � Depth . ♦ Filler Material 50'-)l J- . .,.1 .F .k s TYPE OF SEPTIC WORK: NEW INSTALLATION ,,.REPAIR/ADDITION U (No septic tank or seepage pit permitted ifpublicQ { v , p sewer i s Installation will serve: Residence Commercial _ Other available within 200 feet.) Number of living units; ` ' t n 9 Number of b6drooms ' Lot size fffvlll ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg WO Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity P y Method of Disposal SEWAGE SYSTEM Distance to nearest: Well S� 7� Foundation Pro party Zine 1 y DESTRUCTION ❑ � p y LEACHING LINE ❑ No. & Length of lines �{� Total length size Q` FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Dept /q X fa Size isNumber SUMPS tance to nearest: Well Foundation Property Line ; DISPOSAL PONDS Cj 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, i Home owner or licensed agent's,signature certifies the following: "I certify that -ir 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 workmanIs compensation laws of California." Contractor's hiring or sub-contractingsignature certifies the following: "I certify that in the performance of the work for which this permit is issued, shall emp,Koy -plprsors subject to workman's cowpersation[laws tof�talifornia." The applicant mu t call f mall required inspections'."', Complete dra 'n on r' v rse side.-�---i Signed X t Title: Date: DR: ARTMENT USE ONLY ; Application Accepted by �j r J' Area p EJ $tk 466-6781 i/ Additional Comments: — # Lodi 369-3621 Pit or Grout Inspection by Date Ll¢' i w ❑ Manteca 823-7104 i #, Final Inspection by Date — ! Ll Tracy -835-6385 r Applicant - Return all copies to: Environme Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y A FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 3"i ;� vy \ i 10/82 500 14-26