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k ------------ Y APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT q rr 1601 E. HAZELTON AVE. STOCKTON, CA !I Telephone (209)466-6781 PERMIT N0 PERMIT EXPIRES I YEAR FROM DATE ISSUED' DATE ISSUEDy � �`' (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein described. This application is made in compliance with San Joaquin County Ordinance No. e and the Rules and Regulations of the San Joaquin Local Health District. `�9 for sewage or No. 1862 for well/pump [ Jot) Address I Owner's Name •Subdivision Name Address Contractor's Name II License No. Phone QE�.��-t!rx Phone TYPE OF WELL/PUMP WORK. NEI WELL ❑ +WELL REPLACEMENT p� ' PUMP INSTALLATION ❑ DESTRUCTION❑ DISTANCE TO NEAREST: S1;pTIC TANK 1 SYSTEM REPAIR ❑ OTHER SEWER LINES DISPOSAL FLD. FOUNDATION I AGRICULTURE WELL PROP. LINE �- OTHER WELL PITS/5UMP5 INTENDED USE --- --- TYPE bF WELL PROBLEM AREA I❑ Industrial CONSTRUCTION SPECIFICATIONS LJOpen;Bottom [] Manteca Dia, of Well Excavation (� Domestic/Private 0 Gravel Pack ❑ Public ❑ Trac ry Dia. of Well Casing L] Other Delta Ll Irrigation A Type of Casing ❑Cathodic Protection Depth ❑ Eastern P Specifications Geophysical Depth of Grout Seal t _ ❑Other Type of Grout I Repair Work DoneT Surface Seal Installed by ❑ Type of Pump H.P, State Work Done Well Destruction U Well Diameter ~� Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION JJ REPAIR/ADDITION i tR� (No septic tank or seepage pit permitted if public sewer is W Installation will serve: Residence �—eCommercial Other available within 200 feet.) Number of living units: -,/— Number of bedrooms Character of soil to a depth of 3kfeet: Lot size S G SEP€IC TANK F ❑ Type/Mfg f Water table depth ❑ Type/Mfg PKG. TREATMENT PLT. Capacity No. Compartments Capacity �`�_ Method of Disposal - Distance.t nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines J J FILTER BED ❑ Total length/size o ♦.,x Distance tnearest: Well %S4 Foundation' ` Property Line ,f Q SEEPAGE PITS Depth ,� 1 Size Number SUMPS LJ Distance to nearest: Well DISPOSAL PONDS t ./- Foundation =j Property Line ` 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 per on in such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub-contracting sig Lure certifies the following: "I certify that in the performance of the work for which this permit is 'ssued, I shall employ p ons subject to workman's compensation laws of California." The applican 11 for ' re a ins tions. Complete drawl Signed X l reverse side. _ Title: /t....� _ Date: f -� FOR DE ARTM USE ONLY Application Accepted by Additional Comments: Area d S Stk 466-6781- W; Pit or Grout Inspection by Lodi 369-3621 Date Final Inspection by ' Manteca 523-7104 Applicant.- Return ail copies to: Environmental Health Permit/Services el 01 E n Ave.,gl 0 Tracy20 835-6385 09, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED INFO I RECEIVED BY DATE PERMIT NO, EH 13-24 , REV. 10/82 14-26 10182 500