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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 (o PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED �S3 (Complete in Triplicate) r 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 Regulations f the Sa aq Local Hea1th�Dis�t�ict. C� r_ Job Address-% b1 itYon Name J o Owner's Name �s'�C+�c-lam-- �..�' C •,Q �i.ess _ b �jd.yy�g3� c��,j11 R_h'one Contractor's Name '��,�cS License No. Phone h. TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION �) PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLO. PROP. LINE 6- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOPS Industrial ❑Open Bottom ❑Manteca - Dia. of Well Excavation 6 W ❑ Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing _ 6 ❑Public ❑Other ❑ Delta T [ Irrigation ation Type of Casing _ 00 J 9 Approx. ❑ Eastern Specifications y, ❑Cathodic Protection Depth Depth of Grout Seal Geophysical ❑Other Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done _ Well Destruction Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below SO') �1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other , Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK [Jr Type/Mfg Capacity a No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. a Length of lines \ Total length/size FILTER BED ❑ Distance to nearest: Well t!!S Foundation Property Line SEEPAGE PITS Depth - Size Number SUMPS U 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% 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 p ica must cal r required insp ons. Complete drr-awing on reverse side. Signebg Title: R Date: EPARTMENT USE ONLY Application Accepted by .Rih Area/-/'yo•Z — (pl#MLanteca tk 466-6781 Additional Comments fws4g,�iS u �� 1,e ;4 51 a �Ad M.SaMQ_I odi 369-3621 Pit or Grout Inspection_,, b� Date �-7�� 823-7104 Final Inspection by� if LC7 w�9 Date/%/— X � ❑ Tracy 835-6385 Applicant - Return all copi s to: Environmental Health Permit/Services/1601601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �iS. 1-15 r, o p � ��/iZy�3 83- 1131e ` .H 13-24 REV. 10/82 \ �� 10/82 500 4-7A