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APPLICATION FOR PERMIT '! SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 t0`�cJ "8 PERMIT EXPIRES 1 YEAR FROM PATE ISSUED' DATE ISSUED � (Complete in Triplicate) Application is hereby made to the San Joaquin Local Healt �District fora pernit'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 t and the Rules and Regulations of,the San.Joaquin Local Health3. District,. Job Address t E.a� �rj +.,I�1 S Subdivision Name t owner's Name Address ¢ Phone 410 Contractor's Contractor`s Name PA Cts License No. Phone 6� _ OCA TYPE OF WELL/PUMP WORK: NEW WELL. WELL REPLACEMENT, .� DESTRUCTION � . PUMP INSTALLATION (� SYSTEMREPAIR " OTHER yCi U.a DISTANCE TO NEAREST: -SEPTIC TANK SEWER LINES DISPOSAL,FLD:4;'__"1 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL z PITS/SUMPS , -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, } J Industrial U Open Bottom Manteca- Dib. of Well •Excavation ' r Domestic/Private U � Gravel Pack .�� Tracy, Dia, of Well Casing Public � Other �. Del to _ ( irrigation Type of Casing ation `J - i 9 •,Approx. ❑ Eastern Specifications L Cathodic Protection Depth17 p Geophysical Depth of Grout Seal a LJ Other Type of Grout Surface Seal Installed by M Repair Work Done FJ_ Type of Pump H.P. State Work Done ' Well Destruction U Well Diameter Sealing-Material (top 501) Depth Filler Material (Below 50') { TYPE OF SEPTIC WORK: NEW INSTALLATION — REPAIR/ADDITION T U {No septic tank or seepage pit permitted if public sewer is — — «C 1}U�^ available within 200 feet.) Q` Installation will serve:. Residence Commercial Other �c.<�f' Number of living units: — Number of bedrooms Lot size Character of soil to a depth of 3 feet: _ ��ONE:- " Water table depth qP9D' SEPTIC TANK Type/Mfg Q YD S�L Capacity /60o .No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity ,Method of Disposal f SEWAGE SYSTEM Distance to nearest:. Well Foundation Property Li DESTRUCTION ❑ Line , � LEACHING LINE No. & Length of lines t .-- Q Total-length/size 'X t FILTER BED ❑ Distance to nearest: Well —L5v--+Foundation Property Line lot r SEEPAGE PITS Depth _ ZS Size Number _ 3 SUMPS _ LDistance to nearest: Well I �$ Foundation '7�• Property Line DISPOSAL PONDS C �� + �-� - t 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. q 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 iring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit i issued, I shall employ ersons ubject"to workman's compensation laws of California." a The applica Y-fo 11 req ' d s e d o Complet draw on reverse side. - Signed X Title: Date: FOR k NT USE ONLY ? Application Accepted by kohl Area _ Stk 466-6781 Additional Comments: ,_ Lodi 369-3621 ' Pit or Grout Inspection by Gy / Jj Date r✓v O Manteca 823-7104 Final Inspection by Date {s D ,? Tracy 835-6385 Applicant - Return all copies to: . Environmental Health Permit/Services 1601 H zelton Ave., P.O. Box 2009',Stk., CA 95201 FEE BASE AMOUNT DUE.,,..J, AMOUNT REMITTED RECEIVED BY F DATE PERMIT NO. INFO VS L4 up to Z 8�3 83 l01 tv EH 13-24 REV. 10/82 10/82 500 14-26 , r