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APPLICATION FOR PERMIT ? r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CAl Telephone (204) 466-6781 PERMIT N0. ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 3110 g t (Complete in Triplicate) _ .17 -55'0 -ig 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 (0 Subdivision Name Y FWry,�a ��,,; � /Ilq,s►I F?f p. f+ t. Owner's NameH S � c.[rf Qaslr�.r..~� Address 1— • �� DC7 Phone Contractor's Name License No. Phone o� TYPE OF WELL/PUMP WORK: NEW WELLWELL REPLACEMENT W N ❑ [� DESTRUCTIOI�, ` a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing G �� ❑ Public ❑ OtherDelta 7 ] f Lj Irrigation ❑ Type of Casing Approx. E] Eastern Specifications F-1CathodicProtection Depth ❑Geophysic`al Depth of Grout Seal ❑other Type, of Grout N 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 ❑ (No septic tank or seepage pit .permitted if public sewer is Installation will serve: Residence _ Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity MetKSod of Disposal l SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ p y LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS + t_! 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 LocaT 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 tobecome 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 for all required inspections. Complete drawing on reverse side. Signed X Title: Date: QR DEPARTMENT USE ONLY Application Accepted by 7/ � Area /- ❑ Stk 466-6781 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't . . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. d INFO �3-I J3 .f EH 13-24 REV. 10/82 !' � { ` 10/82 500 14-26 .z -