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APPLICATION-FS'PERMIT '{ _ a IVI SAN JOAQUIN LOCAL HEALTH DISTRICTS �� 1601 E. HAZELTON AVE., STOCKTON,.0 JULq } NO. Telephone (209) 466-6781 ULi8`E DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) "SAN JOAQUIN LOCA1. Application is hereby made to the San Joaquin Local Health District for a permit t cadorinqali the(work herein described. This application ,lIs made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump -and the Rules Regulat-onslof the San.Joaquin•Local Health District. dress r ' Jab Ad , �f Sub ivision me Owner's Name Address Phone Contractor's NameMWV*W1 License No. Phone f TYPE OF WELL/PUMP WORK: I NEW WELL ❑ WELL REPLACEMENT F-1. DESTRUCTION ElPUMP, INSTALLATION [] SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .,. INTENDED USE I�TYPE OF WELL PROBLEM ARE"1'_t CONSTRUCTION SPECIFICATIONS ❑.Industrial };,, Tg Open Bottom ❑Manteca m „ Dia. of.Well Excavation Domestic/Private F1 Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public F71 Other ❑ Delta Type of Casing ❑ Irrigation Approx. ❑ Eastern Depth Specifications ❑Cathodic Protection I Depth of Grout Seal CJ Geophysical Other Type of Grout Surface Seal Installed by Repair Work Done Type ofPumpH.P. State Work'Don i' -`"—` Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth ��. Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is .Il, available within 200 feet.) Installation will serve: rResidence _ Commercial _ Other Number of living units: �V Number of bedrooms Lot size Character of soil to a depth of 3 feet: p t Water table depth tA SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments p PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION Q $ LEACHING LINE ❑ NoT A Length of lines Total length/size FILTER BED ❑ Di;stance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number i -SUMPS ❑ Di'stance-tovnearest:—Wel-1-- =--Foundation----,--- �--Property=Lire = � i DISPOSAL PONDS ❑ i I hereby certify that I hovel;prepared this application and that the work will be done iri accordance with San Joaquin county ordinances, state laws, and��ules and regulations of the San Joaquin Local Health District. ; Home owner or licensed agents 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's 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." I The applicant st callN'hli req fired i pec(' ns. Complete drawing an r v rse side, Signed X Title: Date: FO PARTMENT US NLY tf Application Accepted �hy 4 " Area / 3 � Stk 466-6781 Additional Comments:I; y IZ'` pP{J iN ❑ Lodi 369-3621 Pit or Grout Inspection by 4 Ilate ❑ Manteca 823-7104 Final Inspection by '�� Date 2bn5j5 / -1Tracy 835-6385 Applicant - Return all copies to: Environmental Heal h Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 I�. FEE $ASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT 'N 0. S . 10/82 500 .EH 13-24 REV. 10/82 s 14-26 i ---