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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 I DATE ISSUED 3�$� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete ,in Triplicate) E 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 Regulatio�ns/of the San Joaquin Local Health District. Job Address ��- �, _/ti/. �Gsubdivision Name Owner's Name �i]W r_- Address Phone Contractor's Name JC26&0License No. _ Ph6nel��`�fat1 __ i TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT 0 DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL`FLO. PROP. LINE FOUNDATION AGRICULTURE WELL =OTHER WELL _. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a Industrial U Open Bottom q'Q.Manteca r Dia%of Well Excavationli F-1 Domestic/Private ]`Gravel Pack w❑Tracy Oia.1of Well Casing 0 Public F-1 0ther D Delta Typejof Casing U Irrigation Approx. ❑ Eastern = DSpecifications Depth , [ Cathodic Protection P Depth.of Grout`Seal -_ Geophysical Type of Grout f It r Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State,Work Done _ '' + *'� Q Well Destructibn ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') . TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer 'is n r available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number of-bedroomsLot;size . +� Character of soil to a dep h of 3 feet: :' Water table depth SEPTIC TANK Type/Mfg , Capacity. No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well ///p* Foundation r Property Line /,o DESTRUCTION LEACHING LINE No. & Length of lines Total length/sizONE e . FILTER BED Distance to nearest:Well Foundation Property Line SEEPAGE PITS '� Depth ` y JP Size fs Number _ 1 w SUMPS v �� Distance to nearest: Well / -A- Foundation J0� -"Property Line "DISPOSAL PONDS ❑ "* 1 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 "ssued, I shall empl persons subject to workman's compensation laws of California." The applic call all uire spec 'ons. Comple a dr on reverse side. -g _ Signed Title: ✓L�� 'I Date: fa+' R DEPARTMENT USE ONLY Application Accepted by Area -StkrV 4b6-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date LL Manteca 823-7104 Final Inspection by Date Tracy 835-6385 j Applicant - Return all copie to: Environments Health Perm it/Ser ices 1601�telt Ave., P.O. Box 2009, 5tk„ CA 95201 ! FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE FPERMIT0. INFO •� EH 13-24 REV. 10/82 _ 10/82 500 14-26