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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA-, PERMIT NO. Telephone (209) 466-6781 DATE I55UE0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) E Application is hereby made totheSan 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 Regulations of the San Joaquin Local Health District. Subdivision Name --isA..e�}T2 a-, Job Address " - Owner's Name E!. ae2ltST- __ Address Phone Contractor's Name A el, ij 44-G`1Q_._ License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ w �WPUMP INSTALLATION ❑ SYSTEM :REPAIR,, cr OTHE Q``� sT��N �� DISTANCE�_-TO NEAREST: SEPTIC TANKA r .ti SEWER LINES DISPOSAL FLD. PROP. LINE i ' FOUNDATION -AGRICULTURE WELL, OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION a ❑ Industrial ❑ Open Bottom ❑ Manteca Oia. of Well Excavation i ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public Other Delta �J I �. .. .�.. _.�, Type of Casing ❑ Irrigation Approx. ❑ Eastern Specifications Cathodic Protection i� .. fk [3 Cathodic Depth of Grout Seal f. ❑Geophysical _ Type of Grout O 17 Othert= Surface Seal Installed by I Repair Work Done ❑ Type of Pump i H.P. State Work Done! Well Destruction ❑ Well Diameter -^ —Seal ing-Material-(top,50'')-.- Depth Filler Material (Below 50;) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic.-tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: ResidenceX Commercial" "Other Number of living units: _L Number of,bed rooms i =Lot size M Character of soil to a depth of 3 feet: Water table depth � � r SEPTIC TANK Type/Mfg ! 4, Capacity ' &6m e,A LNo. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation ` Property Line DESTRUCTION tt LEACHING LINE No. & Length of- lines - --}- � r T Total length/size FILTER BED Distance to nearest. Well Foundation Property Line SEEPAGE PITS' ❑ Depth Size Number SUMPS Distance to nearest . :;,We11 , "Foundation Property Line ; u DISPOSAL PONDS O M4 I hereby certify that I have prepared this application and that the work will be done in accordance Awith 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§ comp�n`sation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which t this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call r a 1 required inspections. Complete drawing on reverse side. ,,., .. . a ; Date: Signed X Title: rOR DEPARTMENT USE ONLY Area Stk 466-6781 Application Accepted by ❑ Additional Comments: � EJ Lodi 369-3621' Pit or Grout Inspection by Date Manteca 823-7104 Final 'Inspection by _ , 7�I _ Date Tracy 835-6385 Applicant - Return all copies to: Environm 1 Health Permit/Services 1601- E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED 'RECEIVED BY DATE PERMIT NO. INFO , 3 s/s►i� s 3 i EH 13-24 REV. 10/82 10182 500 14-26