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+ r APPLICATION FOR PERMIT'.. ' SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone'(209) 466-6781 � DATE.ISSUED , ( PERMIT EXPIRES 1 YEAR FROM DATE ISSUED^ 3 (Complete in Triplicate) ' Application is hereby made to the SaPioaquin 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 L TA AJC Subdiivision Name Owner's Name Address cJ�` J01e&70AJ Phone r ' Contractor's Name _ rf/.�C " License'No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ D€STRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ;i 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 industrial ❑Open'Bottom µ❑Manteca r, Dia.of Well Excavation V Domestic/Private ❑Gravel Pack ❑ Tracy Dia, of Well CasingLl I PublicDelta•�'�� . " -❑Other ❑ Type of Casing Irrigation Approx. []Eastern Specifications ? ❑ i Cathodic Protection Depth l Depth of Grout Seal ❑1 Geophysical Type of Grout s i Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P,., <., State Work Done Well Destruction--F--i Well Diameter Sealing Material (top°50') i '� Depth s Filler Ma�ter�ia}� (Below 5O') �. � TY..PE OF SEPTI'C-WORK:'"NtW7'INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is y ; x available within D0 feet.) 'Installation will serve: Residence Commercial Other ZOO .�!Number of living,units: �-""Number of bedrooms Lot size l�7 ` Character of soil to a depth' of 3 feet: V NLS -___ Water table depth , t SEPTIC TANK ❑. Type/MfgE i Capacity No. Compartments 4 PKG,,TREATMENT PLT. ElType/Mfg � . Capacity Method of Disposal 1, SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line 'DESTRUCTION LEACHG LINE, �P No. & Lfength of INlines Total length/size GD X 13 FILTER BED ^ ❑ Distance to nearest: Weli Foundation .20 Property. Line } - + Number 'SEI=PACE PI-TS +!! ❑ Depth Size� 5 .._ _, - i SUMPS C f., 4 jJ Distanc}e to nearest: Well Foundation Property Line P I DI-SPO-SAL PONDS [] I hereby certify 'f hat I have prepared this application and that the work will be done in accordance with San Joaquin county or.)iinances, state laws, and rules and regulations of the San Joaquin'Local Health District'. i Home owner or licensed agent's signature certifies the following: "I-certify that in the performance of the work; for which this permitsis ,issued„ I shall not employ,any person in such manner as toybecome-rsubject—to-workman;s 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." € I s.cant S The appTI' m t ca for require inspections. Complete drawing on reverse side. Signed X ., ' Title: Date: , I FOR D �MENT USE ONLY � ' _ // 6781 1 Application Accepted by !4 � ► � /1„ _Area Stk 466- ; # Additional gComments: ❑ Lodi 369-3621 k, Pit or Grout Inspection by 1 Date Manteca 823-7104 Final Inspection by { .P/L ck-t— date �/ $�j ❑ Tracy 835-6385 Applicant - Return all copies to:) Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E ,FEE BASE AMOUNT, DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT N0.' tt !INFO _.-rw 10/8 1 '-.rw�...,wr�i... -.,,,.-n,+rwr,.+,.r...w_..-w...+t_•_.e....r,� - ...++,.,.r3. .«.�...5 i' w....r - --'wr-_'.,x^Hi N-7- - EH 13-24 R€V. 2 0(82 500 14-26 `