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f} ` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 R u ions o the Say poaquin Local Health District. Gt Addr__ ! ~H Su ivision Name t JobRd r s Q � I` Owner's Name �! l Address es r azi Phone Contractor's Name 4 1 1 License No. 7. Phone — D . TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRCTION (❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FCD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial [ Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing s ❑ Public ❑ Other. Delta Type of Casing ❑ Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth s Depth of Grout Seal ❑Geophysical Type of Grout Lj Other Surface Seal Installed by Repair Work Done F] Type of Pump H.P. .State Work Done ,-, . + Well Destruction F-1 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION } REPAIR/ADDITION D (No septic tank or seepage pit permitted�(if public sewer is I ava'.lable wt thin 200 feet.) Installation will serve: Residence � Commercial _ Other i Number of living units: Number of bedrooms 3 Lot size _ I �-{ Character of soil to a depth of 3 feet: / Wtgv'�. I Water table depth J�4 P" SEPTIC TANK Type/Mfg] em . ,f Capacity 8'' No. Compartments . PKG. TREATMENT PLT. ❑ Type/Mfg Capacity r `.M�eiyhodf Disposal. Septic Tank Distance to nearest: WelFoundation J� Property`Line I LEACHING LIKE ❑ No. & Length of lines Total length/size, FILTER BEDL] Distance to nearest: Well Foundation Property;Line , P SEEPAGE PITS ❑ DepthSize Number s ' SUMPS a ❑ Distance.to nearest: Well Foundation Property,iLne It c=` DISPOSAL PONDS � I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county s ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I i,`I\ Home owner or licensed agent's signature certifies the following: "I certify that i0 the performance�of the work for,which this. permit is issued, I shall not employ any person in such manner as to become subjectito workman§ compensation laws of California.. Contractor's hiring or sub-contracting,.signature'certifieszthe^fol -41 'lowing: TIIcertify that in the performance of the work for which this permit i!,,issue , I shall ploy pers ns subject to workman's compensation laws of California." The applican ��tV0, c 1 fo eq it inspections; 'Complete drawing on reverse side. Signed X Title: Date: r � R ZART EN•T USE ONLY Application Accepted by '""""""" 'Ar d�,�"� S , 466-6781 Additional Comments: ❑ Lodi , 369-3621 Pit or Grout Inspec#ion by +�..Date �--t — - 7104-7-104 Final Inspectionby / Date Tracy 835-6385 Applicant - Return all copies to: Envi o mental, Health Permit/Services 1601 E. Hazelton`Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH-13-24 REV--10/82—�.'�"""" `"_"' o=. ... w _.,r. 10/82"500"P �....- 14-26 ,,,