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APPLICATION.FOR PER;f,IT SAN JOAQL'i', LOCAL NcALTH.uiSTR[CT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 J t Q Je Subdivision Name Owner's Name H _ / N Address I Phone Contractor's Name 41( PX' License No. 11Z�p S ;� Phone TYPE OF WELL/PUMP WORK: NEWiWELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLO. PROP. LINE } FOUNDATION k AGRICULTURE WELL OTHER WELL PITS/SUMPS W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �} Industrial ❑ Open Bottom Manteca Dia. of Well Excavation jJ Domestic/Private Gravel Pack Tracy Dia. of Well Casing 117 Public ❑ Other Delta Type of Casing F-1 Irrigation Approx. ❑ Eastern Depth Specifications ❑ Cathodic Protection P Geophysical Depth of Grout Seal ❑ Other Type of Grout Surface Seal Installed by Repair Work Done ) Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [j REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence available within 200 feet.)_ Commercial _ Other Number of living units: Number of bedrooms Lot size 5� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. EJ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED DistanceIto nearest: Well Foundation Property Line SEEPAGE PITS Ej Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line - 1 DISPOSAL PONDSbe n (4 -k)�- l� - "C ;'� •k] I hereby certify that I have prepari ed this application and that thi work will b 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 shall employ persons subject to workman's compensation laws of California." The applicant must call a re u' ed inspections. Complete dr ing on reverse side. 1 _ Q Signed X i Title: /� � Q ,(+ Pater — U r -Le DEPARTMENT USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: U ❑ Lodi 369-3621 Pit or Grout Inspection b Date ❑ Manteca 823-7104 Final Inspection by % Date S ❑ 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 4 �-- 5 Y 3-317 EH 13-24 REV. 10/82 10/82 500 14-26