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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL,HEALTH DISTRICT 1601 E. HAZELTON AVF., STOCKTON, CA PERMIT NO. (1� r `�7S Telephone (209).466-6781 / DATE I55UE0 ! 2-.�23 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �r (Completes in21pl icate) ' 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_Regulatihe San Joaquin Local Health District. Job Address �r �P�3�Ei Subdivision Name Owner's NameJ Address. f. n r r Phone Contractor's Name �Il,_Y!l LF _ License:No. • A. .i Phonq�►.y�W�, 3 W TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ JJ PUMP»INSTAL-LATIONy _r_-SYSTEM.REPAI.R q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE W !FOUNDATION a AGRICULTURE WELL OTHER WELL PITS/SUMPS s - INTENDED USETYPE OF WELL PROBLEM ARS' CONSTRUCTION SPECIFICATIONS I r� F-1 Industrial = U Open Bottom to Q•Manteca Dia, of Well Excavation �J l U Domestic/Private Gravel Pack ITracy Dia. of Well Casing Pubiic F-1 Other ❑ Delta. a Type of Casing V irrigation Approx. Eastern h ' Specifications"* ❑ Cathodic Protection Depth .1 f. a Depth of Grout'Seall Geophysical Type of Grout /'tf Other i t �3 1 Surface Seal Installed by Repai Work Dane ❑ i Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 7 Sealing Material,(top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW-INSTALLATIaN a REPAIR/ADDITIONy� (No septic tank or epage pit permitted -if public sewer is "'"": ayailableYithin 200 feet.) Installation will ser07 Resadeiicer Commercial _ Other i ; Number of living units;s _' Number of bedrooms L%at size C/(/� Character of soil to a,dept of. 3�eet- f j C I Water table depth SEPTIC' TANK�'-,;' ".°,�t Type/M=fg00, r t Capacity Na . Compartments _ PKG. TREATMENT PL_T, F7 Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM-S?' 4 Distance to nearest: Well Foundation Property Line-. DESTRUCTION' � f il,*- 1Z_ g 1 LEACHING LINE No. & Length of lines 20�,YU ';Total length/size fid ` FILTER BED - "FDistance' to-nearest: Well s Foundatidh .� Property Line .� j. j SEEPAGE PITS Depth Size Number f� SUMPS Distance to'nearest: yWell _ Foundation %pFl- Property.Linep� DISPOSAL PONDS:,f' A` ❑ N. ti / •I hereby certify that I have prepared thfsiappl.ication and that the work will be done in accordance with San Joaquin county ordinances, state laws, andl-rules,;and`:regulations.ofl`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 subject to workman compensation laws of California." n in—'such as to become su p permit is issued, I shall not employ any perso s 3 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 applicant must call or al equired inspections. Complete drawing on reverse side. s Signed X _.�� ,Title:.` Date: OR QQARTT USE ONLY / Application Accepted by _ Area Stk 466-6781 / Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection -Date L Manteca 823-7104 i ' `�-•-' Final Inspection by _ Date 1 - -$3 Tracy 835-6385 v�, 5 '=�"pApplicant - Return all copies to: Environmental Health Permit/Servi-c es 1501 E. Hazelton Ave., P.O. Box 20D9, Stk., CA 95201 Vii � ''FEE' -A'B'ASE" 4 —AMOUNTS..-DUL4 ...,.-AMOUNT,REMITTED RECEIVED BY _ DATE _ *p7 PERMIT N0. ° INFO � 4S 3�s -..-.--rte EH 13-20. REV. 10/82 yj l; 1D/82 500 14-26 t. V "