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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 4 (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 Joaquin Local Health District. i Job Address Subdivision Name .4.Ai C—dZ;qAP_b # Owner's Name4.- Address po/J-06, '4K4W Contractor's Name t License No. 4y Phones 7� i TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR lE OTHER U DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES' DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (y } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ti Industrial U Open Bottom [] Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing �] Public FOther Delta Li Type of CasingIrri Irrigation Approx. Eastern Depth Specifications Cathodic Protection p . Depth of Grout Seal Geophysical Other , Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') }7�J TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION [(No septic tank or seepage pit permitted if public sewer is I ,. available within 200 feet.) � Commercial Other Installation will serve: Residence . Number of living units: _ Number of bedrooms, �_ ,�,:. Lot size Character of soil to a depth of,3 feet: Water table depth SEPTIC TANK T e . Cj yp g Capacity No. Compartments PKG. TREATMENT PLT. C Typ�Pg Capacity Method of Disposal SEWAGE SYSTEM Distance to"nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE FAwl' No. & Length of Nines_ .f — / Total length/size s 2 FILTER SED Distance to nearest: Well A&A Foundation �,S/ Property Line i SEEPAGE PITS Depth Size Number I i SUMPS �� Distance'to nearest: ;We1T `A Foundation �9 s Property Line DISPOSAL PONDS 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 rulesrand regulations of..the San Joaquin Local Health District. Home owner or licensed,agent's signature iWti'fTes th'e'followirig: "'I certify that in the performance of the work for which this permit is issued, I shill 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 1 this permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 The applicant must call for all required ins ions. Complete drawing on reverse side. Signed X Title: Date: —Ze, DEPART Application Accepted by ea ,C5jJ—Stk 466-6761 Additional Commen E] Lodi 369-3621 Pit or Grout Ins ction by Date 3 2�� ] Manteca 823-7104 Final Inspection by Date g— Tracy 835-6385 Applicant - Return all co ' s t Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 FEE-+I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 3 -d-0 EH 13-24 REV. 10/82 10/82 500 14-26