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Qi APPLICATIDN FOR PERMIT SAN JOAQ61N LOCAL HEALTH DISTRICT �� Ub 1601 E. HA7.ELTON AVE., STOCKTON, CA `' ' '` PERMIT NO. Telephone (209) 466-6781 SAI` JOAQUiN LOC;k ED,��T� DATE ISSUED PERMIT EXPIRES 1 YEAR FROM GATE I55U (Complete in Triplicate) DISTRICT 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 Ordinarce No 549 for sewage or No. _1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, z�2tf/pNS l 7�"/yetirl Job Address c LDo�.R' 149&-1 S f-D Subdivision Name ! Owner's Name �! s a Address / Phone �3l0i35r/ Contractor's Name Jf4:r&r ,,t JV±r P _ License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U 'f/jf/.► PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK Ja SEWER LINES JiLCe¢- DISPOSAL FLD. [ PROP. LINE FOUNDATION Lam/ AGRICULTURE WELL r- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j kI ndustrial pen Bottom Ej Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Tracy Dia. of Well Casing L7 Public CJ Other E Delta Type of Casing Lj Irrigation Approx. [ Eastern Specifications I16 U �� J� Cathodic Protection Depth - 0 ❑Geophysical Depth of Grout Seal U Other Type of Grout ,_yl Surface Seal Installed by t yid tA Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U 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 available within 20D feet.) (b Installation will serve: Residence _ Commercial Other } Number of living units: Number of bedrooms Lot size / Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK I-] 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 U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS F-1 Depth Size Number SUMPS 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 applicant gest call for_9,11 required inspections. Complete drawA on reverse side. Signed Title: oADate: ' (a `` ,, Fd EPART NT US Y Application Accepted by!./- _ _ IVrea Q Stk 466-6781 Additional Comments: 09 [] Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date r ey 835-6385 Applicant - Return all copies to: Environmptal Health Permit/Servi-c es 1601 E. Hazelton Ave. P.O. Box 2009, Stk., CA 45201 FEE BASE AMOUNT DUE -,+AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26