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J APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT l 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 j i PATE IssuED � D PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k (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 -r3 SFeAw Subdivision Name k Owner's Name &11,V -L-1 Address a �el ;Z 47 Phone 3S-' `/4 Contractor's Name &AA 45GW .l_ License No. Phone � # TYPE OF WELL/PUMP WORK: NEL! WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ C� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER-L=INES DISPOSAL FLD. PROP. LINE _---FOUNDATION AGRICULTURE WELL' " - OTHER WELL PITS/SUMPS �n 'YINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCIiO SPECIFICATIONS ' Industrial ❑ Open Bottom- 'Manteca Dia. of-Well Excavatio m.mn ❑ Domestic/Private ❑ Gravel Pack ❑Tracy. Dia. of Well Casing Public Other Delta 1 ❑ ❑ ❑ ;r%, Type of Casing } L iIrrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth 'Depth, of Grout Sea F---_7x ❑ Geophysical k r ; Type,of Grout ❑Other -- - - Surface S al Instal ed by Repair Work Done ❑ Type of,Pump� -` = H.P. State Work Done! k_ Well Destruction ❑ .Well Diameter Sealing Material (top 501} x r Depth _' _ _� sv - Filler Material (Below 50') kA ` r TYPE OF SEPTIC WORK:. NEW INSTALLATION , REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is V" 7 available within 200 feet.) Installation will serve: Residence--V— „Commercial,` Other �* Number of living un its:A- _ Number of bedrinloo/ps Lot size , A Water table depth Character of soil to a depth of 3�feet C f/ lliDf'4'. TS EP IC TANK ❑ Type/Mfg , Pf Capacit No. Compartments � :- PYG. TREATMENT PLT. ❑ 'Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to-nearest: Well 316 Foundation Property Line k DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines 4W �al length/sizer) � FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS ❑j Depth Size Number 5 /�-.- Property I SUMPS Distance to nearest: Well Foundation �C_ Line _ DISPOSAL PONDS ❑ } I hereby certify that I have prepared this!applica-tion 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 fallowing: "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 hirin6 or sub-contracting signature certifies the following: "I certify that in the performance of the work for which y this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applic n ust call for 1 requiredco ons. Complete drawing on reverse side. r '� Signed c Title: Date: FO PARTMENT USE ONLY � s _ �] Stk 466-6781 Application Accepted by Area , Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by " „"—"•"'•""`Date "❑-Tracy- 835-6385 Applicant - Return all copies to: Environ eftal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952DI i FEE BASE OUNT DUES AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 r.ap: T14-26