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V C) APPLICATION FOR PERMIT SAN JOAQUiNI LOCAL HEALTH DIST,'R,ItT,. 1601 E. HAZELTON AVE_ STOCKTON, CA Rh1 Telephone (209) 466-6781 T T�I AUED PERMIT EXPIRES I YEAR FROM DATE [S$7 �c,.,, gy £ —�/�� (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 Lo al Health District. Job Address_ 1001 1:5. 0!-r/WS 14, Subdivision Name Owner's Name WJ 1 ;5 Address. _14"Of - &, AhiDejri�W &'0 Phone Contractor's Name License No. �q 0�0 1 9 1 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION F-1 PUMP INSTALLATION SYSTEM REPAIR OTHER [3 _1�s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial E] Open Bottom Manteca Dia, of Well Excavation r7 n Domestic/Private�60-eIstiD Gravel Pack Tracy Dia. of Well Casing Public 0 Other ❑ Oel ta. Type of Casing Irrigation Approx. Eastern F1 Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal ❑Other Type of Grout Oone Surface Seal Installed by Repair Work Type of Pump -st.Al H.P. State Work Done �P�Bu I L Well Destruction ❑ Well Diameter — Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve-. Residence Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK [] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line .SEEPAGE PITS F-1 Depth — size Number SUMPS LJDistance to nearest: well Foundation Property Line DISPOSAL PONDS 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 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 workmancompensation 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 ised,, f I shall employ persons subject to workman's compensation laws of California." The applicant call e uired. ecti . Complete drawl �a n reverse side. Signed X : �� I Date: T E ONLY Application Accepted Area E] Stk 466-6781 Additional Comments EJ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date LTracy 835-6385 Applicant - Return all c le o: . Environments 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 79 _Z EH 13-24 REV. 10/82 10/82 500 14-26