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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 San Joaquin Local Health District. Job Address 110011 k,4 1'0>a Subdivision Name Owner's Name rAISS _ Address .Jkt,,1411DN £ Phone (�] Contractor's Name P.1. IL WG61. EQU.>tPJileir rse No. "3J L0 Phone IthOL-3012 1 TYPE OF WELL/PUMP WORK: NEW WELL ] WELL REPLACEMENT DESTRUCTION Cj 41 N PUMP INSTALLATION ( SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION L AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation El Domestic/Private Gravel Pack [] Tracy Dia. of Well Casing !—] Public F-1 Other Delta Type of Casing U irrigation Approxi ❑ Eastern Depth g Specifications Cathodic Protection g Depth of Grout Seal Geophysical 17 :. Type of Grout _ Other 4 Surface Seal Installed by Repair Work Done Type of Pump H.H.P. �Z+ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) 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.) Installation wifl 'serve: Residence._ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of;�oil to a depth of 3 feet: Water table depth SEPTIC TANK 0 .� Type/Mfg F Capacity No. Compartments PKG. TREATMENT PLT. "Type/Mfg a Capacity Method of Disposal Distance to .nearest. Well Foundation Property Line LEACHING LINE U No. & Length'of lines Total length/size nl FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth ` t Size e, Number SUMPS 0 L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 3 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 iss ed, I shall not employ any,person in such manner as to become subject to workman!s compensation laws of California." Contractor's iring or su ontracti si'gna ure certifies the following: "I certify that in the performance of the work for which this permit issued, I h 1 em perso subject to workman's compensation laws of California." The applic ust call or 1 e in ections. Complete drawing on reverse side. � 11tt �� Signed X Title; ^ �' � ELLDate: EP MENT USE Application Accepted byLli�7a�.sai ea d tk 466-6781 Additional Comments: F-1 Lodi 369-3621 Pit or Grout Inspection b Date ❑ Manteca 823-7104 Final Inspection by Date --lL— [] Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ^�DATE PERMIT N0. INFO _p 02—yv2 �fH,13-24 REV. 10/82 10/82 500 14=26