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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ] ! 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. D L/ Telephone (209) 466-6781 DATE ISSUED Ia 3 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 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 Sian Joaquin Local health District. Job Address T/1/ Ad G�AIIN Subdivision (Name Owner's Name �'/Q�Al4 Gest'AOS Address �/y 4VR W S>1 f Phone _ 9'30-,-3 Y.z Q Contractor's Name ftlir License No. Phone QV 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom ❑ Manteca-- Oia. of Well Excavation Domestic/Private ❑ Gravel Pack 0.Tracy ..,,,,,Dia. of Well Casing ❑ Public ❑ Other ❑ Delta {Type of Casing Irrigation Approx. ❑ Easterni 'Specifications ❑ Cathodic Protection Depth F Depth of Grout Seal ❑ Geophysical j Type of Grout U Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter I Sealing Material (top;50') — Depth Filler Material (Below 50') r n TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) T Installation will serve: Residence _ Commercial _ Other Number of living units: Number of be Lot size F Water table depth Character of soil to a depth ofi3 feet: - SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 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 applicantmust call for all req u.red inspections. Complete drawing on reverse side, Signed X Ji_i .,.+1- Title: V�O/f/e4K Date: FOR DEPART ENT�LSE YO oZ �Stk 466-6781 Application Accepted byAreaAdditional Comments: s �C �i�/l�ilt.r' ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Ir, Date '�3 ❑ Tracy 835-6385 Applicant - Return all copies to: Envirormental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 8ASE AMOUNT DUE i AMOUNT REMITTED RECEIVED BY DATE PERM IT NO 10/82 500 EH 13-24 REV. 10/82 14-26