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i APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DiSTRICT �� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, X14 Telephone (209) 466-6781 3 DATE ISSUED E 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 of the San Joaquin Local Health District. Job Address '� r d S1&iviSion Name CY1001 1� t� on Owner's Name Address . BOX . 11 0 San Jose 1 OFSone Contractor's Name 1 License No. —.371560 Phone 462-5597 -- TYPE 6 —TYPE OF WELL/PUMP WORK: NEWIWELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR 17 OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD:4 PROP. LINE 013 FOUNDATION E AGRICULTURE WELL OTHER WELL i PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial U Open �Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia, of Well Casing Public [—I Other Delta Type of Casing LjIrrigationAeprox . Eastern Specifications i ❑ Cathodic Protection I p Depth of Grout Seal EJ Geophysical Type of Grout i U Other Surface Seal Installed by y Repair Work Done Type of Pump H.P. ).State Work Done Well Destruction (gf 4Well Diameter., 'J 1 1 Sealing Material (top 50') 5 g a P m i x __ — Depth _38:2* Filler Material (Below 50') concrete TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other f Number of living units: Number of bedrooms Lot size f Character of soil to a depth of 3 feet: 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 DESTRUCTION a LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line } SEEPAGE PITS F-1Depth ') Size Number SUMPS �� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C� I I hereby certify that 1 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 sh employ any person in such manner as to become subject to workman compensation laws of California." Contractor's hiring o s -con i Signa re certifies the following: "I certify that in the performance of the work for which rthis permit i ss d, s a 1 p y perso subject to workman's compensation laws of California." �9The applic t c f 1 r q e tions. Complete r w' g or reve J s e ��4� -�� M Signed X Title: �/ Date: F E MENT USE ONLY QS Ix Stk 466-6781 Application Accepted by Area Additional Comments: E Lodi 369-3621 Pit or Grout Inspecti b 01 te D Manteca 823-7104 Final Inspection by Date L7 Tracy 835-6385 Applicant - Return all copie n0 ronmental 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 � �„� � -2N F L� 10/82 500 t EH 13-24 REV. 10/82 14-26