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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT- c Q?� L� J 1601 E. HAZELTON AVE.,- STOCKTON, CA PERMIT NO. U ✓ Telephone (209) 466-6781 /� r • �° DATE ISSUED',2.11 l0 II SY 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 x described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump �i and the Rules and Regulations o the San Joaquin Lo al ealth District. c` Job Address Subdivision Name s C Owner's Name Address Ci'r--t - Phone W Contractor''s Na License No. ` Phone le?t. 'S I j I� -TYPE'FOF WELL/PUMP WORK: NEW WELL ❑ ,WELL REPLACEMENT ❑ DESTRUCTION [j ttz • PUMP INSTALLATION [] 'SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES', DISPOSAL FLD. PROP. LINE . FOUNDATION AGRICULTURE WELLa OTHER WELL PITS/SUMPS INTENDED USE 'TYPE OF WELL PROBLEM AREA 1�, CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑Manteca Dia, of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of-Well Casing.__ ❑ Public Cj Other [] Delta Type of Casing F jIrrigation Approx. ❑ Eastern / _ ❑Cathodic Protection Depth Specifications' Depth of Grout_5eal, _ ❑Geophysical t Type of Grout U Other ; Surface Seal Installed by Repair Work Done ❑ Type of Pump Ji.P. State Work Done - I Well Destruction [[—J Well Diameter Sealing Material (top 501) Depth j Filler Material (Below 501) L(j TYPE OF SEPTIC WORK: NEW INSTAILA7ION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is c/ available within 200 feet.) Installation will serve: Residence _ Commercial v Other �` Number of living units: Number of bedrooms ^- Lot size t Character of soil to a depth of 3 feet: �' Water table depth D ' SEPTIC TANK, E] Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE [_J No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation T Property-Line . SEEPAGE PITS Depth Size_ - Number SUMPS L� Distance to nearest: Wille Foundation Property Line DISPOSAL PONDS ❑ f ✓ r I hereby certify that I have prepared this application and that the work will be doneyin accordance with'San Joaquin county . ordinances, state laws, and rules and regulations bf'the'San Joaquin Local Health District. Home owner or licensed agent's signature certifies the fol Towing: "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 workmans compensation laws d"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." The applicah1t must c f all required inspections. Complete drawing n arse side. Signed X _ Title: Date: FO PART ENT USE ON App cation Accepted by Area f E] Stk 466-6781 Additional Comments: -R Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE FBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Io EH 13-24 REV. 10/82 10/82 '500 14-26 ..