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I APPLICATION.FOR,PERMlT SAN JOAQt -LN LOCAL. HEALTH DISTRICT — 1601 E. HAZELTON AVE.,-STOCKTON, CA PERMIT N0. Telephone (209) 466-5781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S (C mplete in Triplicate) Application is hereby made to the San Joaquin Local ealth 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 0r'No, 1862 for well/pump and the Rules and Re uI t/I, of the San Joaquin Local Health District. # Job Address 1_" \-�' -:�, A Subdivision Name IJ Owner's Name i Address ( Phone Z _ Contractor's Name �� • p�5' �f a�4r'Qpnse No, 4 PhonLT' � � Y TYPE OF WELL/PUMP WORK: NEWWELL WELL .REPLACEMENT ❑ DESTRUCTION ❑ �_ PUMP INSTAL ATIOJ SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE o FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial �� ❑ ai en Bottom Manteca Dia, of Well Excavation _2Domestic/Private ❑ Gravel Pack [:].Tracy Dia, of Well Casing �❑ Public ❑ Other ❑Delta Type of Casing Irrigation4 Approx. ❑ Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal P 2err„_ ❑Geophysical Other w Type of Grout T a A c;r Surface Seal Installed by ^Repair Work Done E] Type of Pump_ H.P. fL State Work Done -Re Destruction Lj Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence e "Commercial Other Number of living units: Number of bedrooms Lot size Character of�9oil to a depth of 3 feet: Water table depth 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 A ❑ No. & Length`of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size s Number SUMPS l—1 Distance to nearest: Well k Foundation b'. Property Line DISPOSAL PONDS ❑ -4 i, i ✓ t, r e .s I hereby certify that I have prepd'r-ed 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 �daquin 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-Conti-fitting signature certifies the following: "I certify that in the performance of the work for which `thi`s permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant mu t call f all required iwections. Complete drawing on reverse side. �) Signed X 'tle: Date: f d G FO EP T USE ONLY Application Accepted by Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit oGrout )nspection by Date ❑ Manteca 823-7104 Final Inspection by Date '&/ ❑ Tracy 835-6385 Applicant - Return allcopies o: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED- RECEIVED BY DATE PERMIT NO. INFO $ loS EH 13-24 REV. 10/82 10/82 500 14-26