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APPLICATION FOR PERMIT rw - SAN JO AQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ` Telephone (209) 466-6781 [ DATE ISSUED ` PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to %e--SA 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 I and the Rules and Regulationsf 'Oe San Joaquin Lo HeaTtstrict, �-[y �SS— vim Job Address !/ �h vi .Na 73j.�-cp /�- Owner's Name AddressPh _ one � 2 2— IfContractor's Name e� ice=se No. Phone_ rk t TYPE OF WELL/PUMP WORK: NEW'IWELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR _ 4L?� OTHER F1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PIT$/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial U Open Bottom [] Manteca Dia, of Well Excavation Domestic/Private + Illi. LJ � Gravel Pack Tracy Dia. of Well C f 1 acing � , Public Other Delta 1 1 Type of Casing i Irrigation Approx. EasternSpecifications ❑ Cathodic Protection Depth'11 Depth of ,Grout Seal 17 Geophysical U Other 1 Type of Grout 1. Surface Seal Inst led by nZ Repair Work Done Type of Pump' l�c�y - H.P. v State Work Done ;LI Well Destruction U Well Diameter! Sealing Material'(top 50')t - Depth ! Filler Material {Below 5dd i ziA, o � TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septi talk or seepage pit permitted if.public sewer is .. e b available within 200 feet.) Installation will serve: Residence _ Commercial _ Other 1 J } i Number of living units: ,'.'Number of bedrooms _ Lot size , Character of soil to a depth of 3. feet: Water table depth SEPTIC TANK L Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. U Type/Mfg Capacity , - Method of Disposal SEWAGE SYSTEM Distance[a nearest: Well Foundation i Property Line DESTRUCTION ❑ , LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation � JProperty 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 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 per mitis 'sued,-I shall employ persons subject to workman's compensation laws of California," The applican st 11 f required i pections, Complete awing on reverse side. Signed Xitle: Date: r QR—DEPARTMENT USE NLY Application Accepted by 9,e9 Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ,�i-- Tracy 835-6385 Applicant - Return all copies to: it nm ental Health Permit/Services 1601 . Har ton Ave„r'P,O, Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. 1 INFO e AcH-0-93 83- 1-1Y1 1 EH 13-24 REV. 10/82 s 10/82 500 14-26