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APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH,DISTRICT 1601 E. HAZELTON AVE., STOCKTON,.CA.- PERMIT NO. Telephone (209) 466-6781 _ PERMIT EXPIRES I YEAR FROM DATE ISSUED 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 Band the Rules and Regulations of theLSan,Joaquiin Local Health District, Job Address ry: 1S9'31 ' --rS I ✓ EAAS Subdi vision Name ' Vrol S Owner's Name "' }: Address Phone Contractor's Name !L &r4Lt3l License No., Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER F1 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 , Industrial E ❑Open Bottom F-1 Manteca Dia, of Well Excavation } U Domestic/Private E]Gravel Pack ❑ Tracy Dia. of Well Casing Public Ej Other 0 Delta Type of Casing F—JIrrigation Approx. ❑ Eastern EJ Cathodic Protection Depth Specifications Depth of Grout Seal LJ Geophysical Other Type of Grout 1-1 Surface Seal Installed by Repair Work Done Q Type of Pump H.P. State Wdrk.Done Well Destruction Well Diameter Sealing Material (top 501) Depth Filler Material. (Below`50') 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_ Other c Number of 11,ving units: --I— Number of bedrooms Lot size A Character of soil to a depth of 3 feet: _ Pn Water table depth SEPTIC LANK , Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well `'r Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines Total length/size FILTER BED Distance to nearest: WellA Foundation Property Line SEEPAGE PITS 4 Cj, Depth_ Size,'� { ..Number SUMPS ,n,4 U Distance to nearest: WeliFoun_dation Property Line DISPOSAL PONDS 1 A jr k 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,tKe 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." The applicant must ca] for ll reqVed inspections. ,—Complete drawing on reverse side. �^ t Signed X� �` �r�G Title: ' /�ty-- / Date: Ar—Ci FOR DEPARTMENT USE ONLY Application Accepted byArea Stk 466-6781 Additional Comments: 0 Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 ° Final Inspection by Date 44o�� ❑ Tracy 835-6385 Applicant - Return all copies to: EAvironmedVl Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _ o t FEE BASE AMOUNT DUE AMOUNT REMITTED . RECE-IVED BY '�._DATE-, y_ PERMIT.N0. 'INFO" ., • EH 13-24 REV. 10/82 10/82 500 14-26