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r. Pfy APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate) Application is hereby made to the San.•Joaquin Local Health District for a permit to construct and/or install the workherein 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 of the San Joaquin Local Health District. Job Address Q �� g5;_,yjPfip Subdivision Name Owner's Name Address Phone Contractor's Name License No. � _ Phone TYPE OF WELL/PUMP WORK: NEW WELL f] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION [] SYSTEM REPAIR 0 OTHER 1 t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I1 AGRICULTURE WELL -f.,. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (] Industrial Open Bottom [f Manteca Dia. of Well Excavation L7 Domestic/Private Gravel Pack Tracy Dia. of Well Casing ❑Public G Other []Delta Irrigation Type of Casing 9 Approx. [� Eastern Cathodic Protection Depth •_f Specifications Depth of Grout Seal,, Geophysical Type of Grout [�Other j� Surface Seal Installed by Repair Work Done Q Type of Pump H.P. State Work Done , Well Destruction's Well, Diameter Sealing Material (top 501) + C Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW,INSTALLATION REPAIR/ADDITION U (No septic tank or seepa9e pit permitted if public sewer is f+ , available.within 200 feet.), Installation wiil`serve:, Residence' Commercial _ Other Number of living units:` Number of bedrooms �� Lot size &•tJf Character of'-soil to a dept of J feet: iy/? Water table depth i SEPTIC TANK Type/Mfg' iI P} Capacity No. Compartments PKG. TREATMENT PLT. Type/MfgII Capacity Method of Disposal Septic Tank Distance to nearest: Well ZIL Foundation Property Line Destructionr 47— ❑ �. _ LEACHING LINE No. d Length.of lines �� Total length/size ! FILTER BED Distance to'.nearest: Well q 3~/ Foundation Property Line SEEPAGE PITS Cl Depth — Size Number SUMPS U Distance to;nearest: Well Foundation Property Line DISPOSAL PONDS Cl t r , I hereby certify that I have.pr,.epared 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,�$rsijnafure 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 applicant must cal Y Porrequired;inspections. Complete drawing on reverse side. Signed X ,��z�� =-t ,' i Title: Date: B Appllcatlon �ccepied by '.FOR DEPARTMENT USE ONLY Area _Z 7 �3 l3 ❑ Stk 466-6781; Additional C' nts: V :; ❑ Lodi 369-3621+ Pit or OroutfInspection by °`"- % Date �nteca 823.71041, Final Inspection by Date Z Z- Tracy 836.6386` Applicant - Return 6.13_copl.do.- o:.—Envlronmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 96x01 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. a INFO -meq a2 5D0 ._,...— EH-13.24-•�--REY•,.:;10/B2 to/ 14.26