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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT �j ? 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ` Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 wel l/pump and the Rules and Regulla/tai/qns of thelSa/n-Joaqu^ifn Local//},1/9al th District. Job Address '�/`1 CA- f,/Jl /� i Subdivision�/Name nn. ho Owner's Name - p Q V Address a�7�y E {�-A Jr- .PPS K Phone Contractor's Name � QTf.7 License No. Phone ` TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing Public ❑Other ❑Delta Type of Casing - Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal _ ❑Geophysical - Type of Grout ❑OtherSurface Seal Installed by Repair Work Done E] Type of Pump H.P. State Work Done = Well Destruction ❑ Well Diameter Sealing Material (top 501) _ -Depth Filler Material (Below 50') C y� TYPE OF SEPTIC WORK:- NEW INSTALLATION ( REPAIRIADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve Residence :- Commercial _ Other z Number of living units ! Number of bedrooms _ Lot size /60 X /k4 Character of soil-to a de t f 3 feet: .- Water table depth SEPTIC TANK ❑' Type/Mfg - Pep Capacity /too No. Compartments PKG. TREATMENT PLT. ❑ Type/*9-.' Capacity Method of Disposal SEWAGE SYSTEM ` Distance t6 nearest: Well Foundation Property Line DESTRUCTION -' ./ LEACHING LINE No. &;Length of Tines I _ /f)CI Total length/size 0 0 I FILTER BED ❑ Distance to nearest: We110�1 Foundation plAer�bl Property Line -�— 6' SEEPAGE PITS ❑ Depth" Size 7 Number L SUMPS Q� Distance to nearest: Wel lelle<(DQ/ Foundation &4"� /d0I Property Line / DISPOSAL PONDS - ❑ S I S n oeA er/ W/�• 6 1 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 rulgs and regulations of the San Joaquin Local Health District. iS7Yl°1, ' of the work for which this Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance ` permit is issued, I shall not employ any person in such manner as to become subject to workmant 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." The applicant t call all 1 .red inspections. Complete dra}y�g on reverse side. Signed x 'c2 Title: 7/!/1 7i / Date: SIL �' F R PEP 4 . USE ONLY ❑ Stk 466-6781 Application tep ed by Area D�fJ . Additional Comments: - . E] Lodi 369-3621 V Pit or Grout Inspection by , Date N-Manteca 823-7104 Final Inspection by Date —a��3�` ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental He Permit/Services 1601 E. Hazelton A P.O. Box 2009, Stk., CA 95201 FEE I BASE AMOUNT DUE AMOUNT REMITTED �]/RlE/L�E IYED BY DATE PERMIT�N`O..p INFO O �-L7s O LEH 13-24 REV. 10/82 orl 10/82 500