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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ] Telephone (209) 456-6781 r� ]1 DATE ISSUED � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) , Application is hereby made to the San Joaquin Local Hedlth 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. 7 Job Address Subdivision Name Address Phone Cf —�/^�3IV Owner's Name ,.y)17/a(g��rJ%`i(=!� .----- i Contractor's Name License No, Phone 511V B{ -^ `x] i TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINE$ DISPOSAL FLD. PROP. LINE n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION$ t Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ] Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications Depth❑ Cathodic Protection - Depth of Grout Seal ❑Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done f Type of Pump 5 Lf H.P. / State Work Done Well Destruction ❑ Well Diameter f Sealing Material (top 50') U! Depth Filler Material (Below 50') lT' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) 11" Installation will serve: Residence Commercial _ Other Number of living units:. Number of bedrooms Lot size Charactero p f soil to a depth of 3 feet: Water table depth r k Capacity SEPTIC TANK ❑ Type/Mfg p y No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal ` SEWAGE SYSTEM Distance to nearest: :Well Foundation Property Line DESTRUCTION ❑ 1 LEACHING LINE No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line E SEEPAGE PITS ❑ Depth Size Number SUMPS ❑! Distance to nearest: Well Foundation Property Line DISPOSAL PONOS �l I hereby certify that 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 permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant�s��cal f all r quired inspections. Complete draw g on reverse side. Signed x J Title.: _ �o ��s�- _ Date: "7�10°��--3 D P RTMEN E ONLY 5tk 466-6781 Application Accepted b Area _ L1 - E]Rdditional Comments: - Yh) E] Lodi 369-3621 Date Cl Manteca 823-7104 Pit or Grout Inspection by Final. Inspection by Date 6 L7 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16 1 E. Hazeltor Ave_ P.D. Box 2009, Stk_ CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10/82 500 EH 13-2T -REV. 10/82 14-26