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`/ APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT 'Q3 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 0 Telephone (209) 466-6781 C n 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 well/pump and the Rules//and Regul tions of the San Joaquin Local Health District. Job Address -Subdivision Name � Phone ��x�� Owner's Name ' Address ,nP Phone No. Contractor's Name License W TYPE OF WELL/PUMP WORK: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE p FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing Public F-1Other []Delta Type of Casing V Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout 0 Other Surface Seal Installed by Repair Work Done E] 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 REPAIP,/ADDITION LJ (No septic tank or seepage pit availableewithin d if u200cfeet.)sewer is t Installation will serve: Residence _ Commercial _ Other lye-)�i j! Number of bedrooms ; Lot size— Number of living units: � Character of soil to a depth of 3 feet: /A � — - Water table depth (1s'( (v Capacity �2(x� No. Compartments SEPTIC TANK Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Type/Mfg /,2SEWAGE SYSTEM Distance to nearest: Well \per Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines xrr Total length/size- � �C Sot �� .. FILTER BED Distance to nearest: Well 1 n�e_ Foundation \o a Property Line SEEPAGE PITS L t Depth _ \ ize _ .SZ Number �= 1_ Foundation Property Line SUMPS Distance ton rest: Well Ck.� DISPOSAL PONDS CI 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 workmahnI& compensation laws of California." t 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 m for 11 requir iC�eti ns. Complete drawing on reverse side. Date: Title: ^ '• ^A n A Signed X--__,_/ ( — — ru tri, _ENT USE ONLY Stk — 466-6781 Application Accepted by Area P—r- Lodi 369-3621 Additional Comments: vvvvvv Manteca( 823-7104 Pit or Grout Inspection by Date Date — ❑ Tracyl- 835-6385 Final Inspection by Applicant - Return all copies to: En vi onmental H h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95 e RECEIVED BY DATE PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED p 2 q 1 INFO � , 5 00 '�'Y1 -5 __7 3 O`)— 403 10/82 500 EH 13-24 REV. 10/82 14-26