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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL 'HEALTH 3ISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 465-6781 DATE ISSUED �$3 PERMIT EXPIRES 1 YEAR FROM 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 and the Rules n ec4.ulations of San Joaquin Local Health District. D {� — _ i Job Address rl- Subdivision Name Owner's Name Lr ess Phone 1I Contractor's Name = License No. Phone rrte''''( TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 0J + PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ 1 DISTANCE TO,NEAREST::SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public L Other C] Delta Type of Casing ". r Lj Irrigation Approx. ❑ Eastern Depth Specifications Cathodic Protection Depth of Grout Seal I❑Geophysical Type of Grout y•�� = . m- �-,--r-nom,,.-- - Other v L D Surface Seal Installed by CIO Repair Work Done Type of Pump H.P. State Work Done. C51 - Well Destruction ❑ Well Diameter Sealing Material (top 50'). Depth Filler Material (Below 50') A TYPE OF SEPTIC WORK: NEW INSTALLATION REl3AIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is k available within..200 feet.) Installation will serve: Residence • Commercial _ Other 4 ` Number of living units: Number of bedrooms Lot size L,5 6, 11 � 0�-) Character of soil to a depth of 3 feet: ;- Water table depth SEPTIC TANK Type/Mfg �.� Capacity No. Compartments Z11 PKG. TREATMENT PLV Type/Mfg F Capacity Method of Disposal [�# � SEWAGE SYSTEM Distance to nearest: Well Foundation �(1� _ Property Line rn DESTRUCTION LEACHING LINE No. & Length of lines Total le gth/size4.1 FILTER BED ❑ Distance to nearest: Well ] Foundation Property Line S . Number rn SEEPAGE;'PhTS r '' ' Depth Size r SUMPS Distance to nearest: Well Foundations Property Line } DISPOSAL PONDS ❑ �x I hereby certify that 1 have prepared t c rdance with San Joaquin county (/ will be done inaco his application and that the work ' pp 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, 1 shall not employ any person in such manner as to become subject to workmant compensation laws of California." Contractor's hiring or su contracting si nature certifies the following: "I certify that in the performance of the work far which , this perrm'i�ls�issued, I shill em play pe sons s bject to workman's compensation laws of California." 'tns Ii nt muall for al. qu x:ed �r4s)act''ons Comple drawing reverse si'dg„__ / r Date: Signed ' Title: F E MENT USE ONLY . Stk 466-6781 Application Accepted by Area Lodi 369-3621 Additional Comments: h Pit or Grout Inspection by Date r LJ Manteca 823-7104 r1 Final Inspection by Date L Tracy 835-6385 o Applicant - Return all copies to: Environmant 1 Health�Permit/Services 1601 Haz,'lton Ave— P.0, Box 2009, Stk., CA 95201 ` FEE BASE AMOUNT DUE AMOUNT REMITTED t RECEIVED BY DATE PERMIT NO. k 1 INFO .10/82 500 ' I i EH 13-24 REV. 10/82v�, ? • l 14-26