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_ APPLICATION FOR,PERMIT SAN .OAQUiN LOCAL HEALTH DISTRICT p2 (� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED -13 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 and the Rules and Regulations ofpthe San Joaqui. L I Health District. Job Address_�g G. +� • ' J^-+ . -Subdivision Name ,;, - Owner's Name Address hone Z,7 I Phone "�4=' vV Contractor's Name License,No. t 013 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑I 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 CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation + L (❑ Domestic/Private i ❑Gravel Pack ❑ Tracy Dia, of Well Casing ` ❑ Public F-1 Other ❑ Delta Type of Casing (❑ Irrigation Approx. [] Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout Other Surface Seal. Installe�kby' Repair Work Done D Type of Pump h.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') } a Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION D (No septic tank or seepage pit permitted if public sewer is Ifffavailable within 200 feet.) Installation will serve: Residence _y_ Commercial _ Other rn Number of living units: Number of bedrooms Lot size76 k —s— Water table depth / Character of soil to a depth of 3 feet: I 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 DESTRUCTION Total length/size LEACHING LINE No. & Length of lines , FILTER BED ❑ Distance to nearest: Well - Foundation ,lj�_ Property Line s Size Number 1 SEEPAGE PITS Depth ,�.1 , " ,. SUMPS LI Distance to nearest: Well Foundationd Property Line DISPOSAL PONDS ❑ I hereby certify that I havepreparedthis application and that the work will be done in accordance with San Joaquin c6unty 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 npt 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 thax in the performance of the work for which < this permit is issued, I shall employ persons subject to workman's compensation laws of California." Theapplic us call for requir i pecttions. Comp to drawjng on reverse side. 777 Signed Title: Date: FORSDEPAIfi3MENT USE ONLY r�� tk 466-6781 Application Accepted bye Gwi� Ci�sis Area �_____ Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection Date jl ❑ Manteca 823-7104 Final Inspection by Date 2 y 1 ❑ Tracy 835-6385 Applicant - Return all copies to: nvironmental Health Permit/Services 16 1 E. H 'Ito, P.O. Box 2009, Stk., .CA 95201 f FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ADATE WPERM . ITNOINFOaq � 10/82 500 EH 13-24 REV. 10/82 `_ -, 'J� /� I4-26 J `_