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X' APPLICATION FOR PERM-! SAN uDAQUi`d LOCAL HEALTH DSiRICT 15CI E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781. PERMIT N0. J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED �' �4 (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 RRee�mations of the San Joaquin L cal Health District. Jab Address `9 a�$ .' f L �� Subdivision Name ' Owner's Name 1�� Address ��-- � Phone Contractor's Name License No. �- Phone T a TYPE OF WELL/PUMPYIdORK: NEW a ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER F DISTANCE TO NEAREST;. SEPTIC TANK) r't SEWER LINES DISPOSAL FLO. 'PROP. LINE �� , `. FOUNDATION ' �` AGRICULTURE WELL OTHER WELL l PITS/SUMPS INTENDED USE 1 TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial (❑Open Bott m Manteca V ❑ Dia, of Well Excavation ❑ Domestic/Private# ❑ Gravel Pack Trac ❑ Public i y Dia, of Well Casing yW v ❑Other ❑ Delta Irrigation i Type of Casing ' Approx. ❑ Eastern. ❑Cathodic Pro ection Depth Specifications mo �. ❑Geophysica3F- Depth of Grout seal FJ Other Ty pi' of...,Grout 4 5ur.face Seal Installed by . Repair Work Done Type of Pump H.P State Work Done Well Destruction ❑) Weil Diameter Sealing Material (top 50') `'^, Depth Filler Material (Below 501) .41 `„ .. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ��1 ❑ (No septic t,k or seepage pit ermitted ifupublic sewer is + Installation will serve: Residence X Commerc4 /Uther avail'ahle within 200 feet.) =� 5 ¢' Number of living units: "" Number ofi.b draoms S4G�S. Y —, � -T Lat size �^ � ,,. Y ,,.�L ,( ' - .Character of sail to a depth of 3 fee : ' ,_�_ Water"ta`b'le dep h ; w CYJ SEPTIC TANK - - _ Type%M:fg ~Capacity No. Compartments. PKG. TREATMENT. PLT. [1] Type/Mfg Capacity . ,ti Method of Disposal ' SEWAGE SYSTEM Distance to nearest: Well FouDESTRUCTION ❑ -� Foundation Property Linew,� LEACHING LINE ❑ No.,& Length of lines Tota-11•engt-h/size FILTER BED ❑ k Distance to nearest: Well d Foundation _ � Property Line..__ SEEPAGE PITS y ED Depth Size Number ` x t; SUMPS ❑ ` Distance to nearest: Well Foundation Property Line �" y 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 He fies the following: alth District. ✓' Home owner or licensed agent's signature certi "I certify that in the performance of the work for wh.i.ch--- is P r's hiriermit J's issued, I shall not emp)oy any person in such manner as to become subject to workman compensation laws of-"Californ-ia-r" - _ Contractor's or sub-contracting signature certifies the following: "I certify that in the performance,of•the wor 1Fdr which his pe>'r is su d, I shall employ Pers subject to workman',s%compensat ion laws of California.,, y he c n u call for all r i pections;-"•Complete drawing on reverse side. ~r � .�r Title>ff �1U. � ,��._^ . � � Date• : �^ ' FOR,.DEPARTMENT-USE ONLY ..� �• :1 ': ° Application Accepted by � / Area `�. � ; Qt k 466-6781 Additional Commenter / ❑ Lodi 369-3621 Pit or Grout Inspection,by� �. Date LJ Manteca 823-7104 E Final Inspection ,by'' - Date /</&� ❑ Tracy 635-6385 Applicant Return all copies to" Environm a Health Permit/Services 1601 F:'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 •� _ .� 1-11 FEEINFO BASE AMOUNT DUE ' AMOUNT REMITTED RECEIVEY, DATE PERMIT NO. A Sao p EH 13-24 'REV. 10/82 14-26 ; CA/ � t 10/82 500