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� d APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 2 II C 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �3 Telephone (209) 466-6781 . r DATE ISSUED a- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'k (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 I 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 s of the Sa Jo quin Local Health District. s Job Address �. Subdivision Name Owner's Name Phone Address / - Phone Contractor's Name License No. f I TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT- DESTRUCTION U-3h PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ,� .. ' OTHER ❑ l'I DISTANCE TO NEAREST: SEPTIC TANK Y ''SEWER`rINES'" P "" '"""' 0-ISPOSAL PL-D: -- - PROP-'LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'INTENDED USE TYPE OF WELL ` PROBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ Industrial U Open Bottom .l ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public [j Other ❑ Delta Type of Casing r` 4f Irrigation Approx. ❑Eastern Specifications Depth Cathodic Protection h ❑ Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done { Well Destruction ❑ Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 50') TYPE OF SEPTIC-WORK: NEW 1NSTALLATION L[ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is 111 available within 200 feet.) '7 nstal-Iation-wil-1-serve:- Residence !' Commercial Other Number of living units: � Number of be rooms �_.: Lot size Character of soil ��epth of 3 fee rj/ ,�jAL�'/ Water table depthSEPTIC TANK Type/Mfg Capacity No. Compartments { PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well ,S- foundation `Property Line 9 DESTRUCTION 1 r- Total length/size LEACHING LINE U No. & Length of lines pQ FILTER BED ❑ Distance to nearest: Well undation L operty Line SEEPAGE PITS Depth Size j 3 Number �+ SUMPS L 1 Distance to nearest:_ Well Foundation Property Liner Lam/ DISPOSAL PONDS ❑ ,� ! M w -�� I 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 sut5jett -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 , a.ws of California." E The applicant m st call for all re i pd inspections. drawing on rev rse side. Title: Date: Signed X FOR DEPA MEN T USE DN LY 5tk 466-6781 Application Accepted by Aread Additional Comments: Lodi 364-3621 Pit or Grout Inspection y F Date - ...:. � Manteca 923-7104 •rac-y_ 8356385Da,teFinal Inspection by it/ServicP.O. Box 2009, Stk.,.CAF`s. 952 01 Applicant - Retuto: , Enviro mental Health Permes 1Hazelton Ave., EE BASE AMOUNT DUE' AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �3-115-7 10/82 500 EH 13-24 REV. 10/82 k 14-26 !i {