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APPLICATIONR FCR ,o ERMIT I iv SAN JOAQUiN LOCAL HEALTH uISTRfCT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, f] SAN JOAQUIiN LOCAL Telephone (209) 466-6781 HEALTH DISTRICT DATE 1ssuEn I PERMIT,EXPIRES 1 YEAR FROM 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 i and the Rules and Regulations of the San Joaquin Loyal Health District. Job Address Subdivision Name - Owner's Name Address {�Phone Contractor's Name `y License,No. Phone 6f -.270 TYPE OF WELL/PUMP WORK: NEWfWELL WELL REPLACEMENT DESTRUCTION ❑ -PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES n DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t Industrial UOpenBottom T� Manteca Dia, -of i.Well Excavation - Domestic/Private Gravel Pack Tracy ' €Dia. of Well Casing ` L7 Public J Other ❑ Delta Gype of Casing OD L, Irrigation Approx. ❑ Eastern e i Specifications f_1Cathodic PrSLec.tioh � lDepth t ; n + Depth of Grout Seal. a Geophysical , Type of Grout I Surface Seal fnstaTle�"-b'y""�-� Repair Work Done Type of Pump r H.P. �. State Work Done ' Well Destruction U Well Diameter Sealing Material;(top,50-,)"%, A s _ �[ Depth Filler Material (Below 501 i - TYPE OF SEPTIC WORK: NEW ,INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage,pit permitted if public sewer is s available within 200 feet.) Installation will serve:. Residence _ Commercial Other Number of living units: Number of bedrooms /` ?'. Lot size._, e Character of soil to a depth of 3 feet: Water table depth fi SEPTIC TANK E] Type/Mfg:1 Capacity No, Compartments PKG, TREATMENT PLT. 0'.'x.4 Type/Mfg -xyf. Capac ity .. Method of Disposal } SEWAGE SYSTEM Di'stancetto'nearest: un ' Well Fodation? Property Line DESTRUCTION '{ LEACHING LINE :❑ No. & Length of lines r- Total].engt•h/size` FILTER BED 17Distance�to nearest:i Well 1 ..� l Foundation :Property Line i SEEPAGE PITS [—I Depth Size ` Number SUMPS - L1 -Distance to nearest:: Well. ! _F66n'dation.aProperty Line' R DISPOSAL PONDS - j 6 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, I sh 11 employ persons subject to workman's compensation laws of Cal,ifornia." The applica ust 11 fo 1 ired inspections. Complet wing onn�reverse side. ----Si.gned-X_- - ri.t].e:• `^�r«� '� _ - — Date: 8411 `r�i �=DEPRREN USE ILY TM Application Accepted by00, � �] Stk 466-6781 s Additional Comments: :+i ti 1- a rf [111-Lodi �,36g-3621- a -* Pit or Grout Inspection Date .r Manteca 823-7104 ., k Final Inspection by ' ' ' Da`te -racy 835-6385' .1 Applicant - Return all copiev. 4,vironmen.taI Health, eXmit/Sery.iceS i.1"601 E.,Hazelto Ave:,.,P.0' Box 2009, Stk„cCA-^9520.1, FEE BASE AMOUNT .DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO FH 13-24 REV, 10/82- - 10/82 500 14-26 -7 o r