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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� I f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 . DATE ISSUED S PERMIT EXPIRES I YEAR FROM GATE ISSUED ' (Complete in Triplicate) ii -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 Regulat'ons the Spn Joaq in Local Health District. Job Address • ivision Name Owner's NameU�G,_,ZAddress j Phone Contractor's Name A04 -License No. 30 6-7,1/ Phone ��'• 5� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ w PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE !!! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial [:)Open Bottom ❑Manteca Dia. of well Excavation 111 Domestic/Private ❑Gravel Pack [:]Tracy Dia. of Well Casing ❑Public ❑Other ❑Delta Type of Casing �j Irrigation Approx. ❑Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical u Type of Grout ❑Other r 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 501 TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION 7.4-0tfO 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 edrooms :It Z Lot size Irf�1� Character of soil to a depth of 3 feet: Water table depth !QD tl SEPTIC TANK C Type/Mfg Capacity No. Compartments '4— PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest:- Well I Foundations Property Line _ DESTRUCTION LEACHING LINE No, & Length of lines ,3 Y(� i Total length/size 1 FILTER BED ❑ Distance to nea-0est: Well _ Foundation % Property Line i SEEPAGE PITS &+,Depth � � `' Size l'• 3 17� Nu er 3 SUMPS U Distance to nearest: Well; Foundation Property Line t� J 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-fol,I owing;•"I,certi'fy thatrin the performance of'the work for which this permit is issued, 1 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�C€FtSfie"s'the fol•lo,ring:, "I 'certify that in the performance of the work for which this permit is issued, I shal empl 14persons subject to workman's codlpensation laws of California." The applic t ust ca for ed inspections. Complete drawing on reverse side. Signed X 1 Title 1. ,/Vtt• Date: FOR DEPARTMENT USE 'ONNLLY .�.. + Application Accepted by Area ❑ Stk 466-6781 Additional Comments: +, Lodi 369-3621 { Manteca 823-7104 Pit or Grout Inspection b Date ❑ =. Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies o: Enviro a It l Health Permit/Services 1601 Haz lto -Ave., P.O. Box 2009, Stk., CA 95201 I FEE BASE AMOUNT DUE -k AMOUNT.,REMITTED RECEIVED BY &ATEPERMIT NO: INFO i EH 13-24 REV. 10/82 a �., 10/82 500 14-26