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APPLICATION FOR.PERM;i f k f SAN JOAQLI`; LOCAL HE71TH DISTRICT 4 * f / I E. HAZELTON AVE., STOCKTON, CA PERMIT N0. �.�r Telephone (209) 466-6781 h1IT EXPIRES 1 YEAR FROM DATE ISSUED -s' DATE ISSUED f"iv 1 �� _(Complete in Triplicate} - t � Application is he r�']`�LIcal 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 �q4 ations of the San Joaquin Local Health District. Job Addressj .` ,-->) Subdivision Name Owner's Name " Phone _:L. -' Address " �_ Contractor's Name __.. u�% X 1C�� ,Address License No. �i�2 Phone fv� TYPE OF WELL/PUMP WORK: NEW WELL P/WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER LI DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES DISPOSAL FLD. pROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ _ i INTENDED USETYPE OF WELL P_ROBL CONSTRUCTION'SPECIFICATIONS ore I lInd strial _ ,. _U Open Bottom anteca >k - -pia. of-Well-Excavation / mestic/Private ravel Pack Ej Tracy Dia. of Well Casing ' 17 Public jOther Delta Li Irrigation Type of Casing A%c_ Approx. Eastern ❑ Cathodic Protection Depth Specifications I--]Geophysical Depth of Grout Seal dro e U Other Type of Grout Surface Seal Installed by y Repair Work Done ❑ Type of Pump H.P, State Work Done 6 Well Destruction U Well Diameter Sealing Material (top 501) a, { Depth Filler Material (Below 50'.) i . � r TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,.ADDITION J (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 .1, Lot size r Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal { SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line 1 DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size �1 ; FILTER BED Distance to nearest: Wel; Foundation f Property Line SEEPAGE PITS ❑ Depth Size Number { SUMPS L I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS f J , I 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 workman 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, [ hall employ persons subject to workman's compensation laws of California." The applicant sty10r alI d inspections. Complete drawing on reverse side! Signed X Title: _ Date: ~- DEPARTMENT USE ONLY Application Accepted by Area _ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection 'nJ 4ked-1 Date Z' 3�'f J Manteca 823-710A Final Inspection by DatefZ ^Z 3 Tracy 835-6385 Applicant - Return all copies to";"-Environmental 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 10/82 500 14-26