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PE '15A APPLICATION FOR PERMIT ' ' SAN JOAQUIN LOCAL HEALTH DISTRICT [ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED i (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 �2_7 Z2 _7�Fl=_ Pj TilV Subdivision Name !e Owner's Name /�lswST. Address iv-.C_ Phone Contractor's Name� o,eJS License No. _ Phone lc • D TYPE OF WELL/PUMP WORK: NEW WELL WELL-•REPLACEMENT [] DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPS 05'WFLL rPROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom f Q Manteca Dia. of Well Excavation- _ _ _ - L) Domestic/Priv-a— M Gra vel,Pack Tracy ~^Dia. of Well Casing 1 Public F-1 0ther Delta Type of Casing 71 Irrigation Approx. E] Eastern Specifications Depth❑ Cathodic Protection - ,Depth of Grout Seal - Geophysical Type of Grout U 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 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION U {No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial X Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: O4;a�' Water table depth SEPTIC TANK Type/Mfg P, s4r>T- Pff-��,i)Capacity wZJ No. Compartments Z- 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 Z ' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation /_5_ - Property Line __JQ SEEPAGE PITSDepth � � Size T��r Number ' SUMPS _ _J Distance to nearest:-�Wel_l-- _Founda.tion �_=` Property Line - DISPOSAL PONDS ❑ f' 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 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." i The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: F FOR DEPARTMENT USE ONLY ❑ Application Accepted by Area � Stk 466-6781 1 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.' Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFOri 10/82 500 t EH 13-24 REV. 10/82 14-26 !