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APPLICATION FOR,PERM7 T ) SAN JOAQL N LOCAL IEA.LTH DISTRiCT -YI 22 Q �j 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Y ( Telephcne (209) 466-6731 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (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 and Regulations of the San Joaquin Local Health District. Job Address - Subdivision Name Own er`s Name �/'- /y„i,! �0-110 Address D Phone Contractor's Name License No. 3 .Z-Z Phone TYPE OF WELL/PUMP 14ORK: NEW WELL F-1 WELL REPLACEMENT DESTRUCTION r , PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U V 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_. O Industrial Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack [ Tracy Dia, of Well Casing Public C1 Other ❑ Delta Type of Casing Irrigation Depth EJ Eastern Specifications ❑ Cathodic ProtectiD on p Depth of Grout Seal L7 Geophysical Type of Grout U Other Surface Seal Installed by I Repair Work Done [f Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION [] (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other 0—L Number of living units:•- Number of bedrooms Lot size 4 Character of soil to a depth of 3 feet: __ _ �, Water table depth E SEPTIC TANK [ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well ' Foundation -Property Line DESTRUCTION LEACHING LINE U No, & Length of lines Total length/siie FILTER BED Distance to nearest: Well Foundation Property. Line SEEPAGE PITS ❑ Depth Size � -Number-"^"" a SUMPS ��Distance to nearest: Well �p Foundation ��_� Property;ine S DISPOSAL PONDS y, I hereby certify that I have prepared this application and thatrthe work will be done in"accordance wYth.San Joaquin county ` ordinances, state laws, and rules and regulations of the San Joaquin"Local Health District. - . hich this Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for w 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." y The applicant m t call for all .equired inspections. Complete drawing on reverse side. //� I r / Signed X __�Titlet, _:�____ Date: f� EPARTMENT US ONLY Stk 466-6781 Application Accepted by Area Additional Comments: '" Lodi 369-3621 i Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date r ❑ Tracy 835-6385 Applicant - Return all copies to:. Environment?He �Per.it�15erices 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 rFFE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. a r 10/82 500 EH 13-24 REV. 10/82 14-26 r