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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT NO. — '1-3 3 Telephone {204} 466-6781 DATE ISSUED Vj3 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. 49 for sewage or No. 1862 for well/pump i and the Rules and Regulations of Pe San Joaquin Local Health District. Job Address / 4 ?- `subdivision Name 1 Owner's Name ' dress Q 3 Phone 34.A , 7J.� Contractor's Name License NoJ Phone TYPE OF WELL/PUMP WORK: fes, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ yj PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Indy ❑ Open Bottom ❑Manteca Dia. of Well Excavation <I- U) 11161 es fc riva ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑ Other Delta Type of Casing 71 Irrigation Approx. Eastern Depth Specifications ❑Cathodic ProtectionDepth of Grout Seal Geophysical - Other Type of Grout j Surface Seal Installed by I Repair Work Done R Type of Pump H.P.' State Work Done I Well Destruction ❑ Well Diameter ✓' Seal'ing Material (top 50') Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION Lj REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is "1 . - I Iavailable within 200 feet.) Q , Installation will serve: Residence _ Commercial _ Other . I Number of living units: Number of bedrooms Lot size Character of soil to a depth.-.o# 3 feet: __ _ Water table depth _ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Lam$ PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal SEWAGE'SYSTEM Oistance to nearest: Well Foundation Property Line DESTRUCTION ❑ ' LEACHING LINE LJ No. & Length of lines w Total length/size - t FILTER BED Distance to nearest: Weli Foundation Property Lire SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 ir.the performance of the work for which E this permit,is issued, I shall employ persons subject to workman's compensation laws of California." The applicantt tt c 11 for 11 equired inspections. Complete drawing on reverse side. / r_3Signed X _�i.�fitIe: Date: FOR DEPAR MENT U E NLY Application Accepted by 74 Area ❑ Stk 466-6781 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 o: Environ ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE Q 2PERM�IIT NO. INFO EH 13-24 REV. 10/82 ` I0/82 500 # 14-26