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i' r APPLICATION FOR PERMIT t SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. C� Telephone (209) 466-6781 PATE 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 ins �'ll�n- described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage and the Rules and Regulations of the Sari Joaquin Local Health. District. Job Address C1 J !(J / Subdivision Name _ Owner's Name Address /15:57 Phone.J� Contractor's Name . - (Ia License No. _92_92_Z Phone TYPE OF WELL/PUMP WORK: :NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industria] U Open Bottom ❑Manteca Dia. of Well Excavation V� ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing V Irrigation A rox. Eastern g Pp ❑Depth Specifications ❑Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout I ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') r` d TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ DDITION , (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Q1.6Installation will serve: Reside a _✓ Commercial Other Number of living units: Number of bedrooms Lot size A,�5 Character of soil to a depth of 3 feet: Water table depth 4 SEPTIC TANK ❑ Type/Mfg Of OOF Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal �* SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEASHING LINE No. & Length of lines Totad length/size Zlit LTER BED ❑ Distance to nearest: Well Foundation — cl Property Line SEEPAGE, PITS ❑ Depth �— Size.2",r Number SUMPS Distance to nearest: Well Foundation ir>!/-Property Line DISPOSAL PONDS ❑ —'�"� - I Hereby certify that I have preparedl this application and tliat.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 compensation laws of California." Cof 'ractor'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 mt t call for ll required inspections. Complete drawing on reverse side. C' Signed X �'""7 Ti tl e `r' Date: FOR DEPARTMENT USE ONLY g Applicat ion"Atcepted IhY 41 Are - E] Stk 4b6-67$1 Additional Comments Lodi 369-3621 Pit or Grout Inspection`b Date ❑ Manteca 823-7104 l Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies o:- Envir mental Health Permit/Services 1601 E. H- zelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO 3 �3-10143 Ili 101 B2 500 EH 13-24 REV. 10/82 14-26