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0 `c APPLICATION FOR PERMIT r SAN JOAQUiN LOCAL rt%LTH DISTRICT 1601 E. HAZELT014 AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-67Bi. DATE ISSUED l r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 4 Application'pis 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 5 n JoaquinAiL--! lth District•lob Address i .Subdivision Name Owner's Name Address Q , �, Phone Phone 4 -7 Contractor's Name Cr. 1 License No. � TYPE OF WELL/PUMP WORK: NEW WELL :t , WELL REPLACEMENT DESTRUCTION U PUMP INSTALLAT ON .� SYSTEM REPAIR j 'OTHER LI DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t 0 ,.I Industrial _ - _"XGrav Domestic/Private el Pack Tracy U_Open Bottom 0 Manteca Di_a.._of,Well Excavation , t Dia. of Well Casing I Delta Pf' Public �other Type of Casing V Irrigation 1W f _'Approx. E]Eastern Specifications e Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout a!IGO U Other Surface Seal Installed by l y Repair Work Done [) Type of Pump H.P. State Work Done 0 i _ Well Destruction U Well Diameter Sealing Material {top 5D'} F Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [71 REPAIR/ADDITION J {No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial i Other Number of living units: I Number of bedrooms Lot size , Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK CJ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distan+e to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ) No. &.Length of lines Total length/size r FILTER BED 17 Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth: size Number _ Distance,_tD;nearest:_ Well — Foundation Property Line SUMPS _ .. =Y. L_I� _ j DISPOSAL`'PONDS 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 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 mploy persons subject to workman's compensation laws of California." The applica u c for a required inspections. Complete drawin on reverse side. Date: signed X Title: .� 9 EPARTMENT E ONLY /�f�r �' W+'466-b781;•:' "S": StV-, Application Accepted by ./ Area ❑ F" .�Kx-• sem€ Lodi., 36'0-3621 ' Additional Comments: i r ' oat, Mnteca 8237104 :: 4= Pit or Grout Inspection by "r i4 DatT"raLy 835-6385 e Ls; Final Inspection by ! o: . Environmental Health Permit/Services 1601 E. Hazelton Ave., p,0.t,'Bpxr2009,fS'tk., ,CA Applicant - Return all copies t {95201 DATE RECEIVED BY -a'sPERM1t7i:hJ0. FEE BASE AMOUNT DUE AMOUNT REMITTED INFQ U 4 EH 13-24 REV. 10/82 Q lr Cf 14-26