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APPLICATION FOR PERI41 T ' SAN JOAQLI": LOCAL HEALTH DISTRICT 1601 L. HAZELTON AVE., STOCKTON, CA PERMIT NO. �L�� Telephone (209) 466-5781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUER DATE ISSUED �,d S (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District far 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 74� Subdivision Name Owner's Name Aa ,:5 Address 6'e, R Phone Contractor's Name License No. Phone _23 2!,11aZ) TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ' ❑ Gravel Pack ❑ Tracy Dia of,'Wefi� {%asing ❑ Public ❑ Other ❑ Delta Type of Casing Li Irrigation Approx. ❑ Eastern Specifications �. ❑Cathodic Protection Depth ❑Geophysical Depth of Grout Seal Type of Grout f_1 Other Surface Seal Installed by 01 Repair Work Dane ❑ 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 U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Resi'dence _ Commercial Y Other Number of living units: ';Number of bedrooms Lot size Character of soil to a depth of+3 feet: Water table depth m .SEPTIC TANK LJ 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 r ❑ No. & Length of lines _/(?_�(��! 1 l�_ Total length/size _ FILTER BED Distance to nearest: Well /5-ar-r-Foundation Zj�f """7 - Property tine p SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance 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 workman s'compensat ion laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of t_he work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California'." The applicant must ca �f 11 req ired inspections. Complete drawing on reverse side. Signed X' `� ,�L.�� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �. Area a; ❑ Stk 466-6781 Additional Comments: _ " ❑ Lodi 369-3621 Pit or Grout Inspectio by Date Manteca 823-7104 Final Inspection by; Date Tracy 835-6385 Applicant - Return all copies`ta:'. EnvOoAh ieAHealth Permit/Services 16� E. Ha el 'n Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26