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W APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� y 1601 E. HAZELTON AVE., STOCKTON,- CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to the San' Joaquin Local Health District for permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin Coun.tyf;0:"" nce No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ? +`` ; Job AddressILI go Subdivision Nametr Owner's Name A dress F x � �f��C,t� __ Phone Contractor's Name - License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ;OTHER ❑ w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l INTENDED USE; TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I J Industrial ❑ Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private F-1 Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑ Other E Delta Type of Casing I iIrrigation Approx. [] Eastern " Depth Specifications I El Cathodic Protection Depth of Grout Seal Geophysical Type of Grout ❑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 501 II TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is j available within 200 feet.) [� Installation will serve: Residence A6-�Commercial _ Other Number of living units: Number of bedrooms 3 Lot size Q.4c►. Character of soil to a depth of 3 feet: r< Water table depth ,Q SEPTIC TANK Type/Mfg _ Capacity .r�G� No. Compartments 2, PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: i Well i u v— Foundation _ Property Line DESTRUCTION ❑ 4, LEACHING LINE No:—&'Length of'lines. A WX.96, „Total length/size J FILTER BED Distance to nearest:[ Well 9p" Foundations Property Line SEEPAGE PITS �rr Depthal� 4. Size :rra. Number ! I r SUMPS LI Distance to nearest: Well, Q' : Foundation's Property Line _ F DISPOSAL PONDS ❑ r�'`. �r 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,, 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 s this permit is issued, I shaA,11 y p rsons subject to workman's compensation laws of California." j I The applicant�alli d inspections. Complete drawing on reverse side. ' , �3 I Signed X Title: Date: OR DEPARTMENT USE ONLY Application Accepted by Area. 5tk 466-67$1 Lodi 369-3621 Additional Comments: Date Manteca 823-7104 Pit or Grout Inspectio I Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all cop .to: Environmental Health Permit/Services 16 4Eazel'ton Ave., P.O. Box 2009, Stk., CA 95201 i s FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO INFOo ICT EH 13-24 REV. 10/82 10/82 500 14-26