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t - r �` y _ t u•V...-` �..=f 1, .+.� � T�•„"'�c� APPLICATION,FOR,PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT /1 1601 E. HAZEL,TON AVE., STOCKTON, CA a Telephon (209) 466-`6781 PERMIT NO. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (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 t and the Rules and Regulations of the Sa Joaquin Local Health District. Job Address 1 /_ / Subdivision Name Owner's Name Address Phone Contractor's Name S license No. Phone ' TYPE OF WELL/PUMP WORK: ,NEW WELL WELL REPLACEMENT DESTRUCTION � y PUMP INSTALLATION SYSTEM REPAIR OTHERI Lf _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� DISPOSAL FLD. FOUNDATION) �r1 t _�[! _ AGRICULTURE WELL OTHERdWELL �- . PITS/SUMPS v, r INTENDED USE TYPE OF WELL PROBLEM AREA IIndustrial CONSTRUCTION SPECIFICATIONSA Gomestic/Private t Bottom E] Manteca Dia. of Well Excavation y4 T .• s � . I [f Open Bo Gravel PackTrac ' G � y Dia. of Well Casing Public Other Delta irrigation g. Type of Casin Irri �-I g Approx. Eastern Cathodic Protection Depth Specifications/. Depth of Grout Seal -)t- Other Geophysical � � U Other Type of Grout ' s g 'ye I Surface Seal Installed by G �y Repair Work Done "Type of Pu+ vim" H.P. State Work Done ! Well Destruction,.Fj Well Diameter �. Sealing Material (top 501) TV Depth t e F.ilier' Material (Below 50') TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/AUDITION-,U (No_septac tan•k,.o.ryseepage pit permitted. if public sewer is . i, ! available.within 200ifeet.)- Installation will serve: Residence _ Commercial *y �Othe . 11 1 Number of living units: Number of bedrooms ' Lot size-� ' ; ' J , ff� �- I Character of soil to a depth of 3 feet: f ( 1 Water table depth SEPTIC TANK FJ_ Type/Mfg Capacity ; i No. Compartments PKG. TREATMENT PLT. [� Type/Mfg `'� Capacity i� . ' Method of Disposal 6' SEWAGE SYSTEM `,*'Distan-ce to nearest: Well Foundation Property Line DESTRUCTION.` LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 1`:� Foundation I Property Line SEEPAGE PITS I Depth.--.:., size I # + `Number SUMPS I-1 Distance to-nearest: Well Founda_ti_o_n, 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, i 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 sha1T not employ any person in such manner as to become subject to workmang 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." 1 The appli ust ail f r all required inspections. Complete drawing on reverse sideL, ��,` Signed + � Title: 1I T 1 '� 7 Date: OR DEPARTMENUSE ONLY -00 Application Accep d by - A ea +�35tk 466-6781 Additional Commen s: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: . nvironmental Health Pe it/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT_REMITTED,,, ,._,_ ,.RECEIVED BY DATE PERMIT NO. INFD 11-4 EH 13-24 REV,. 10/82 10/$2 500 14-26-`' �'1