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APPLICATION FOR PERMIT p 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 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 of the San Joaquin Local Health District. _ Job Address_ ��3 I/�J� �_ Subdivision Name 15 3S VZ12 �� Owner's Name Address /` ►CL �r — Contractor's Name 'A , 4,1' License No. /„Z 'Tl � o o— ° ' �� Phone��l��// v TYPE OF WELL/PUMP WORK: NE4! WELL '�] -' WELL REPLACEMEN7 C 'DESTRUCTION U — 'TMP INSTALLATION'D.'SYSTEM REPAIR'- UT rOTHER U` DISTANCE(TO NEAREST: SEPTIC TANK dI SEWER LINES IDISPOSAL FLD. PROP. LINE i FOUNDATION II AGRICULTURE WELL ) OTHER WELL ) PITS/SUMPS c INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom [] Manteca Dia, of Well Excavation (—I1 1 Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing 1 1-1 Public Other-- Delta Type of Casing LJ Irrigation !Approx. Eastern S� (I Cathodic Protection Depth Specifications p �� Geophysical Depth of Grout Seal 1 17 __TTYPe of Grout t_1 Other! II Surface Seal Installed by _ A. '•�: Repair Work Done �]' ~Type of Pump t r-" H-P. State Work Done Well Destruction CJ- We11 Diamet6lp Y Sealing Material (top 50') ' Depth I( ! i Filler Material (Below 50'): t 1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage:pit permitted if public sewer is �� i•� f' ( available within 200 feet-) Q ,.. Installation will serve: Res'idence Commercial _ Other Number of living uni;s'`_��I Number of bedrooms _ _ Lot size Character of soil to'-a-depth offeet: Dp _ Water table depth f/ �✓ of' feet TANK Type/Mfg p� Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity —_ - Method of Disposal SEWAGE SYSTEM 1 Distance to nearest: Well Foundation / ^F�roperty Line DESTRUCTION ❑ LEACHINGiLINE; 1 i No.. & Length of lines _ c�/G� Total length/size" /tea FILTER BED Distance to nearest: Well Foundation Property LineF'T' SEEPAGE PITS ' CI Depth '� •r Size Number SL14PS „> U Distance.to nearest: Well Foundation Property Line DISPOSAL,PONDS !I I herebycertifythat 1 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 perhit is issued, ]'.shall employ persons subject to workman's compensation laws of California." The applicant must call fQr ai required inspections. Complete drawing on reverse side. Signed X ." Title: Qom., ;�� Date: T y FOR DEPARTMENT USE ONLY Application Accepted by �r Area 1 �E Stk 466-6181 Additional Comments: Ilh ^ �— Lodi 369-3621 Pit or Grout Inspection byli Date Manteca 823-7104 Final Inspection by Date �� (� Tracy 835-6385 Applicant - Return all copies to: Enviro tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk_, CA 95201 , FEE BASE !MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO -- --- — i , EH 13-24 REV_ 10182 " 10/82 500 14-26