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APPLICATION FOR PERMIT 1 j ¢ SAN JOAQU'iN LOCAL HEALTH DISTRICT OCT -• r f 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO.-a -1 1 v v�/1 Telephone (209) 466-6781 SAN JOAQUIN LOCti HATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE. ISS aLT H DISTRICT (Complete in Triplicate) i 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 17663S; 5 0 li Subdivision Name Owner's Name _^ �j %i iek / Address _ Phone Contractor's Name 1 , ti+ S License No. 02.2ID/0 Phone —2-207- aa TYPE OF WELL/PUMP WORK: NEW WELL ] WELL REPLACEMENT DESTRUCTION U CA PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,— INTENDED USE- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N Industrial J'U Open Bottom ❑ Manteca Dia, of Well Excavation LTJ+ Domestic/Private Gravel Pack Tracy Dia. of Well Casing ❑ Public []Other Delta Type of Casing Li Irrigation Approx. ❑ Eastern ❑ Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done Type of Pump, H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of ii.ving units: Number of bedrooms Lot size Character of sail 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 ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED F_� Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑l Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, I shall not employ any person in such manner as to become subject to workmanis 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 applica •m st all for 1 re red inspections. Completeing on reverse side. �y Signed X > / Title: Date: fs ` �/{�'- OR D�USE ONLY Application Accepted by l�S Cin, LY Stk 466-6781 Additional Comments: V.n(eca369-3621 Pit or Grout Inspection by Date 823-7104 Final Inspection by / Date L Tracy 835-6385 Applicant - Return all copies to: Environmental Health ermit/Services 1691 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED �RE/CEEIVED BY DATE q 2 �Q PERMIT NO. INFO i V 4 f `�7__d 3 33—/f� EH 13-24 REV. 10/82 10/B2 500 14-26