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�! r APPLICATION FOR PERM 17 SAN JOAQIIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 q DATE ISSUED PERMIT EXPIRES 1 YEAR FROMDATEISSUED ! (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 Ordinan e No. 549 for sewage or No. 1862 for well/pump and the Rules and Reguldtios of the San Joaquin Local Health District. Job Address Subdivision Name P h Owner's Name'" p Address -3 - 0 Contractor's NameLicense No. Phone l UCTIO TYPE OF WELL/PUMP WORK: 'E NEW WELL WELL REPLACEMENT OESTROTHER L]PUMP INSTALLATION [� SYSTEM REPAIR 17OTHER U DISTANCE TO NEAREST: SEPTIC°TANK - SEWER LINES DISPOSAL FLD, PROP. LINE t/ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` -INTENDED USE -- TYPE OF WELL- PROBLEM AREA- - - -- GONSTRUGTI-0N-SPECIFICATIONS Industrial �. R U Open .Bottbm [❑Manteca Dia. of Well Excavation Dia. of Well Casin - Domestic/Private ❑ Gravel Pack Tracy 9 LJ 17 Public F-IOther Delta Type of Casing Lj Irrigation `! Approx. EJ Eastern Specifications-._ ElCathodic Protection Depth Depth of Grout Seal 17 Geophysical Type of Grout U Other Surface Seal Installed by �+.. State Work Done 'Repair Work Done EJ Type of Pump H.P. - i ` Well Destruction ❑ Well Diameter Sealing Material'(top 50r} - F Depth. Filler Material (Be w 50*) TYPE OF SEPTIC WORK: NEW INSTALLATION E� REPAIR/, ON (No septic tank or seepage piavaermitted if lable withinublic200 fsewer is Installation will serve: Residence 4 Comme ial� �Ottier - Lot-size Number of living units: Number of bedroms -� Water table depth )r3 I Character of sail to a depth of 3 feet: - W '_ — - ,.- SEPTIC TANK Type/Mfg Ca a c i t y No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ;Distance to nearest: Well Foundation Property Line- -L^ r* } DESTRUCTION ( — Total length/size th/size i[ LEACHING LINE No.•& Length of lines b FILTER BED ❑ Distance to nearest: Well CJ" oundation 0 -Prop Ly Line SEEPAGE PITS !!Depth Size Number SUMPS �� 'i Distance to nearest: Well i?q3_. Foundation 'O�F.� Property Line ' DISPOSAL PONDS ❑ :I, r' 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, 1 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 iss Ijshall employ per ns subject to workman's compensation laws of California." The applicant call for all re specticns. Complete drawing on reverse side. 7 / Signed X Title: Date: 2 FOR DEPARTMENT USE ONStk 456-6781 Application Accepted by Area MLodi 369-3621 Additional Comments: _�(ro � Manteca 823-7104 ' Pit or Grout Inspection 4 z , Date Oate Tracy 835-6385 Final Inspection by �s- CA 95201 Applicant - Return all copie 'to. . Envir nmental health Permit/Services 1601 E. Ha elton Ave., P.O. Box 2009, Stk., e _DATE PERMIT NO. FEE BASE l�AMDUNT DUE AMOUNT REMITTED RECEIVED .B Y.. I ' INFO 10-��-�3B 3_ 3 i! � r 10/82 500 . EH 13-24 REV. 10/82 !1 14-26 !I