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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH-DISTRICT rr 1601 E. HAZELTON AVE.; STOCKTON, CA PERMIT N0. <93 r 4 Telephone (209).466-6781 DATE ISSUED y 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) Application is hereby made to the San Joaquin LocalHealth 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 Joa%uiocal Health District. Job Address Subdivision Name . Owner's Name "Address /V T Phone Contractor's Name x!11,* �f-/ - r,, License No. _ e Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION E] SYSTEM REPAIR ❑ OTHER E]DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ „ ji,FOUNDATION.- - - - - AGRICULTURE WELL. 4 OTHER:WELL _ PITS/SUMPS � f i 4 �f INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I ❑Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private' ❑Gravel Pack []Tracy Dia. of Well Casing ❑ Public ❑Other ❑Delta Type�..:....... ype of Casing �jIrrigation Approx. ❑ Eastern I Depth Specifications ❑Cathodic Protection p Depth of Grout Seal I ❑Geophysical Ty ❑Other pe of Grout i ' Surface Seal Installed by j �. Repair Work Done ❑ ' Type of Pump H.P. State Work Done ..� Well Destruction F-1Well Diameter Sealing Materiali(top 50') Depth Filler Material (Below 50') o, i TYPE OF SEPTIC WORK:` NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is - ! I ! available within 200 feet.) Installatiori will serve: Residence _Commercial Other Number of living units: �� _ Number of bedrooms', - Lot size �•,¢r �,� y Character-of soil to a depth of 3 feet:- ,k, Water table depth /�u SEPTIC TANK- ❑ 'Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg j• Capacity Method of Disposal Distance to nearest: Well r Foundation Property Line [ LEACHING LINE LTJ No. & Length of lines J,Total length/size 1 FILTER BED ❑ Distance to.nearest:S Well Foundation Property Line F } SEEPAGE PITS [ f Depth �- ,�'�I Size Number SUMPS ❑ Distance to hearest: Well , J e u Foundation Iy Property Line S ISPOSAL PONDS ❑ I hereby certify that I have prepared this-application and that the work will be donelin accordance with San-ioaquin 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 work6an's compensation laws of California." 6�9� all for all required inspections. Complete drawi g on reverse side. „J Title: r_k 1-3 Aiw3rr4l", _ _ Date: E " t F DEPARTMENT USE ONLY y Application Accepted byArea ❑ Stk 466-678 Additional Comments: ❑ Lodi 369-3621 Pit or Grout InspectionrbyDate Manteca 823-7104 Final Inspection by y�li�-�-.�� Date S $12 ❑ Tracy 835-6385 Applicant - Return all copies to: N Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE ' AMOUNT REMITTED RECEIVED BY 1DATE�j PERMIT NO. LA INFO `A l D� �� `�n S EH 13-24 REV: 10/82 10/82 500 `OO s 14-26